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 What you need to know about your medical aid and PMB

Julia Brown, medical aid consultant:

When people look at a medical aid they look at what they will pay and not always at what they will get for the money they pay. The problem is that people just take the cheapest option and first-time applicants have no clue what they have to look for. Review spoke to a Medical aid consultant, Julia Brown to help people make the right choice.

“People are unaware of the fact that they can be covered for several things under a specified law. This is called the Prescribed Minimum Benefits(PMB),” she says.

Understanding Prescribed Minimum Benefits(PMB)

Healthcare in South Africa is extremely expensive. The cost of medical consultations, procedures and medications continue to rise annually. This is the main reason people look for the cheapest option.

The different medical schemes offers their clients a range of products and medical aid options to suit their essential healthcare needs. Being a part of a medical aid will also grant them access to a number of added benefits which can make all the difference should they, or their dependants, face serious illnesses of many kinds.

“This is something that people do not understand. Not all schemes give the same benefits and not all include the needed services people may need. People look at the cheapest and then when issues arise they find they are not covered for several medical issues or find they are only covered partly and now need to get money to pay. Money they often do not have,” Julia Brown told Review.

As mandated by the Medical Schemes Act, medical aids adhere to a list of Prescribed Minimum Benefits (PMB) on offer to all of their members. The PMB refer to a list of medical and chronic conditions for which you will automatically qualify for benefits from a medical aid, as prescribed by the Department of Health. “There are however some medical aids which are not licensed and because of that do not comply with the law. People can actually go and see if the medical aid they want is registered and can be held accountable if they do not comply. People are unaware of this and believe that if their medical aid does not do what they promised that they have no defense, when in fact they do,” Brown said.

The list includes 270 medical conditions and 25 chronic conditions for which medical schemes are compelled by law to grant benefits to its members. That is, the client will receive benefits towards the cost of diagnosis, treatment and care for the PMB conditions listed, no matter what medical aid plan they are on.

This means that in the unfortunate event that you are faced with one of the serious illnesses listed to receive PMB, you can rest assured that you will be well taken care of.

“Even if you are only subscribed to receive in-hospital cover through your medical scheme, they will still ensure that you receive all the added benefits of PMB while in hospital, as stipulated by law. PMB is a guarantee that clients will receive on-going support and quality, affordable healthcare for the listed condition. In some cases, the PMB may also include chronic medication.”

The 270 medical conditions are diagnosis-specific and fall into 15 subdivided categories such as heart and vasculature; brain and nervous system; or ear, nose and throat. The PMB list is in the form of Diagnosis and Treatment Pairs (DTPs). A DTP links a particular diagnosis to a recommended treatment – one that has been known to offer the best results, is medically approved and affordable.

Besides the above conditions, a further 25 chronic conditions are covered. Chronic illnesses eligible for cover range from epilepsy and asthma to Crohn’s disease and Diabetes (types 1 and 2). For some conditions, prescribed algorithms are used to determine the value of PMB coverage per patient.

“It is important to read through the conditions of your medical aid plan and understand how the cover, pre-authorisation and claims process work. In most instances PMB will also require that you make use of designated service providers in order to receive full cover,” Brown urges.

“It is wise to plan ahead and take control of your future well-being by investing in a quality medical aid scheme that will help lighten your burden when it comes to your healthcare. This fact alone should give you peace of mind that you will be looked after in times of illness, without the added worry of financial pressure,” Brown concludes.