The Prescribed Minimum Benefits (PMBs) are a set of defined benefits to ensure that all medical scheme members have access to certain minimum health services, regardless of the benefit option they have selected on their medical aid. Libcare has to cover the minimum health services related to the diagnosis, treatment and care of:
- any emergency medical condition, as defined;
- a limited set of 270 medical conditions (defined in the 'Diagnosis Treatment Pairs' in legislation);
- and 26 chronic conditions (defined in the Chronic Disease List).
Each of the 270 PMB conditions is linked to a broadly-defined treatment protocol referred to as Diagnosis Treatment Pairs (DTPs). The treatment standards in question are the public sector practice and protocols. In the case of the chronic diseases specified in the Chronic Disease List (CDL), the treatment algorithms that have been published in the Government Gazette are the minimum treatment requirement.
ICD 10 stands for International Classification of Diseases and Related Health Problems (10th revision). These codes are used to inform medical schemes about what conditions their members were treated for so that claims can be settled correctly, e.g. J03.9 is the ICD 10 code for acute tonsillitis.
Because ICD 10 codes provide accurate information on the condition you have been diagnosed with, these codes help the medical scheme to determine which benefits you are entitled to and how these benefits could be paid. In terms of legislation, your treating provider must include the ICD 10 code on your account.
This becomes very important if you have a PMB condition, as these can only be identified by the correct ICD 10 codes. Therefore, if the incorrect ICD 10 codes are provided, your PMB-related services might be paid from the incorrect benefit (such as from your Medical Savings Facility), or it might not be paid at all if your day-to-day or in-hospital benefit limits have been exhausted.
- There are no co-payments on PMB conditions except when members choose not to make use of the Scheme's listed treatments and medicines. Members either have to pay the difference between the actual cost and what the Scheme would have paid, or the percentage co-payment as registered in the Scheme Rules.
- In terms of legislation, co-payments for PMB claims cannot be recovered from the Medical Savings Facility.
Should you or your dependant(s) have more than 24 months' continuous cover with a registered South African Medical Scheme and the break between leaving the latest scheme and date of application to Libcare is less than 90 days, a 3-month general waiting period will be applied but you/affected dependant will be entitled to claim for Prescribed Minimum Benefits.
If you or your dependant(s) were not previously on a medical scheme when you apply to register on Libcare, or if your break between leaving your last scheme and applying to join Libcare is more than 90 days, there will be no cover for Prescribed Minimum Benefits during waiting periods that may be applied.
For more information on PMBs, see the Council for Medical Schemes (CMS) website www.medicalschemes.co.za