PMB’s are a set of defined benefits in the Medical Schemes Act (The Act) aimed at ensuring that all medical scheme members have access to certain minimum health services. They ensure cover for costs related to the diagnosis, treatment and care of : Any medical condition which meets The Act’s definition of an emergency, a limited set of 270 medical conditions and 25 chronic conditions defined in the Chronic Disease Listing (CDL).
Although no limit can be applied to the management of PMB’s, a medical scheme can manage the costs of PMB’s with certain mechanisms: Schemes can ensure the provision of services for PMB’s take place at specific providers known as Designated Service Providers (DSP’s), schemes can implement risk management tools such as formularies for medication or clinical protocols that include clinical entry criteria (diagnostic or laboratory tests confirming the diagnosis). Members who have never belonged to a medical scheme or allowed a break in membership of more than 90 days are not eligible for unlimited cover of PMB’s during either a 3-month waiting period and/or 12-month waiting period on pre-existing conditions. This include emergency admissions during the 3-month waiting period.
A scheme can appoint DSP’s for the management of PMB conditions. In terms of The Act the DSP must include public hospitals. The scheme must ensure that the DSP is able to provide the required service. If not, the scheme must make arrangements for an alternative provider. If you elect not to make use of the scheme’s DSP, you are still entitled to the service for the PMB condition, but funding will be subject to the normal scheme rules which means that applicable co-payments will apply and the claims will be paid strictly at the scheme approved tariff. Please note that in this situation you may be liable for a co-payment if a provider overcharges. That is why it is important to discuss your providers’ fees prior to any procedure.
Identifying valid PMB conditions on diagnosis information alone is not always appropriate, therefore there is an application/authorisation process that is required (PMB Application form). This can either be done before a single event or recurring events (like chronic medication) or after an event such as an emergency. There is also an appeals process for members to query the funding of PMB claims. The appeals committee reviews the case and will contact the member with feedback. Information on PMB’s is also available on the Council for Medical Schemes’ website. Should you require information on the location of the nearest DSP, please contact the Momentum TYB clinical risk management team on (041) 395 4481 or the customer care team on (041) 395 4474.