Prescribed Minimum Benefits: What you need to know

The Prescribed Minimum Benefits (PMB) are a list of 270 medical conditions that medical schemes are always liable to provide cover for, in order to ensure that scheme members are guaranteed a minimum level of cover – regardless of the scheme option they have chosen. Schemes must pay for the treatment of PMB conditions in full, provided that all of the scheme rules have been adhered to.

In an instance where a scheme member has voluntarily made use of a non-designated service provider, the scheme can apply a co-payment requirement to the member if the scheme rules allow for that, even for PMB conditions. It is important that emergency medical providers are aware that just because a patient is suffering from or has sustained a PMB condition does not automatically mean that the provider is entitled to payment for treatment rendered to the patient.

A condition must be a PMB condition and must be such that it either threatens the life of the patient, or can cause impairment of bodily function or dysfunction of a body part or organ, before the scheme is obliged to cover the treatment of the condition. In other words, if a patient is suffering from hypertension, but the level of hypertension is not severe enough that it could be a risk to the patient’s life or bodily function, then the use of an ambulance will not be considered as vital, and a scheme may choose to reject your claim.

By the same token, if a condition is a genuine medical emergency, then even if the condition is not included in the list of 270 PMBs, it will still be considered as a PMB. To make things clear, if a patient is out running and falls and breaks his or her leg, this would be considered to be a threat to the function of a body part and would be covered as a PMB.

It is very important to remember that the PMBs are designed to protect the interests of patients and not necessarily those of the providers who treat them. In a genuine medical emergency, a patient will always be entitled to full cover by a medical scheme, but providers should be cautioned against trying to manipulate a patient’s diagnosis to reflect a PMB condition, as it will not necessarily guarantee you payment for your account.

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