Helping the medicine go down with PMBs

Last updated on 13th December, 2017 at 10:06 am

Being diagnosed with a chronic condition shouldn’t be a life sentence – medically and financially. If you’re a medical aid member, you’re entitled to claim your chronic medication under the Prescribed Minimum Benefits (PMBs) provision of your scheme. Here’s how…

Understanding what constitutes a chronic condition and how you can claim for it from your medical aid is just as critical to your wellbeing as getting the right medicine.

What is a chronic condition?

A chronic condition is defined as a non-communicable ailment that lasts more than three months and which can be controlled, but not cured. Many chronic conditions are related to lifestyle, while others include psychological or genetic disorders or are simply the result of ageing.

What are Prescribed Minimum Benefits?

These are minimum benefits which by law must be provided to all medical scheme members and include the provision of diagnosis, treatment and care costs for:

• A set of 270 conditions as specified in Annexure A of the Regulations to the Medical Schemes Act. Simply put, these are conditions where you would have to be admitted to hospital to undergo treatment or surgery to remedy your ailment.
• Any emergency condition, which is regarded as any sudden change to the state of your health to the point of it being life threatening. For example: a heart attack or injuries from a car accident.
• A list of 26 chronic conditions sometimes referred to as the Chronic Disease List (CDL)

The thinking behind PMBs as they relate to the CDL is that providing continuous healthcare for chronic conditions is far more sustainable than the cost of treating the complications. They are legislated under the Medical Schemes Act of 1998, and provide:

• Medical aid members needing chronic medication with continuous access to healthcare, even when their savings and other benefits have been exhausted.
• Assurance that your medical aid has to pay for your diagnosis, treatment and medication for the specific PMB conditions, irrespective of the cost or if you are being treated at a state hospital.

The Act lists 26 conditions that medical aids have to cover as PMBs regardless of the type of option you have – whether a basic hospital plan or comprehensive cover.

What conditions are covered by PMBs?

• Addison’s disease
• Asthma
• Bronchiectasis
• Cardiac failure
• Cardiomyopathy
• Chronic obstructive pulmonary disorder
• Chronic renal disease
• Coronary artery disease
• Crohn’s disease
• Diabetes insipidus
• Diabetes mellitus types 1 & 2
• Dysrhythmias
• Epilepsy
• Haemophilia
• HIV/AIDS
• Hyperlipidaemia (high cholesterol)
• Hypertension
• Hypothyroidism
• Multiple sclerosis
• Parkinson’s disease
• Rheumatoid arthritis
• Schizophrenia
• Systemic lupus erythematosus
• Ulcerative colitis
• Bipolar mood disorder

To ensure that patients receive optimal levels of care, treatment algorithms have been developed. These are the benchmarks that your medical aid has to adhere to in your wellness regimen. The medical aid may, however, use formularies (a list of medicines they will pay for), treatment protocols and designated service providers (healthcare practitioners approved by your scheme) that you have to use to be covered by PMBs.

What do I need to know?

There is no law that obliges your medical aid or your doctor to inform you that your condition is covered by PMBs or that you can claim your treatment as such. Generally medical aids won’t automatically assign your claim as a PMB. It’s up to you to notify your medical aid that you have a chronic condition and to register as a chronic medication user. They say that your health is your most precious asset, so read the fine print and make sure you know what’s covered and what’s not by your medical aid if you have a chronic condition. By Nicci Both