In the second article of a series aimed to empower patients on their rights in the funding of healthcare, Elsabé Klinck educates us on prescribed minimum benefits (PMBs) – the basic benefits that all schemes, on all options, must provide.

PMBs as your safety net benefits

The PMBs are benefits that all medical schemes, on all options, should fund. It is a minimum safety net, ensuring that all patients, on all options, at least have these benefits covered. 

It is a key element of what makes medical scheme cover “social insurance” as opposed to regular insurance. It therefore cross-subsidises the funding of care amongst all the members covered by that risk pool. The cover is based on medical need, and not on the contribution to the pool. 

Under the PMBs one obtains cover for certain health conditions, irrespective of how healthy, ill or old one is. In regular insurance, one is penalised for one’s health status, age, etc., i.e. for the risk one poses. PMBs are therefore “social security” benefits. People are therefore, through a mechanism of shared (“social”) pooling of funds, covered or insured for specific conditions.

Standardised set of benefits

The PMBs aim to give everyone a standardised set of health benefits. The explanatory notes to the PMB list, which are attached to the Medical Schemes Regulations of 1999, state the objective of this standardised set of benefits, namely:

The objective of specifying a set of prescribed minimum benefits within these regulations is two-fold:

• To avoid incidents where individuals lose their medical scheme cover in the event of serious illness and the consequent risk of unfunded utilisation of public hospitals.
• To encourage improved efficiency in the allocation of private and public healthcare resources.

Implementation

How the PMBs are implemented by schemes should not undermines these objectives. For example, this would be the case where a scheme’s PMB rules require the channelling of patients to the public health sector. This means that one is indeed placing the patient at risk of unfunded care in the public sector. 

It also exacerbates the lack of resources in the public sector system, by requiring private sector patients to join the queue in the public sector, or, worse, to jump the queue because of their private sector, medical scheme status. Medicines and other resources procured for the indigent or uninsured population, now has to be shared with people on medical schemes. 

This means that schemes should not just “transfer” or send patients to an overloaded public sector. Neither should they have the public sector as a designated service provider (DSP) without a proper contract or, in circumstances, where they cannot render the services. They can also not only appoint the state as a DSP, and not have other DSPs. This matter was definitively addressed in the well-known Genesis case in the Supreme Court of Appeal. 

What is included in the PMBs list?

There are 270 diagnostic and treatment pairs (DTPs) that make up the PMBs, and 25 chronic diseases which all fall within the “must be funded” category. All emergency care is also included in the list of conditions that must always be funded. The PMB list can be accessed here:

Because a scheme must fund the PMBs, and one often hears that “PMBs are too expensive”. The 2017 Council for Medical Schemes Annual Report sets the costs of the PMBs as follows:

• It costs, on average, R680 per beneficiary per month to provide the full set of PMBs; and
• PMB costs amount to only 54% of the total scheme risk pool, i.e. 46% of risk pool (i.e. shared) spend goes towards non-PMB conditions. 

This is separate from savings and other pools of money in the scheme (what one could term “non-core care”). 

There are therefore significant portions of medical scheme expenditure that are discretionary to the scheme, and it appears strange that one would aim to erode the core and safety-net of benefits and increase the proportion of non-core, scheme discretionary spend.

Ensuring your PMBs are noted

On a practical level, patients should ensure that the PMB code (an alpha-numerical code appearing to the left of the list of PMBs) are included on accounts and motivations to medical schemes. This is important as it indicates to a medical scheme that the diagnoses (e.g. tests), treatment (e.g. medicines, consultations or operations) and/or care (e.g. by a hospital or therapist) provided, is for a PMBs condition. 

DTP example

The PMBs are listed in DTPs. An example of a DTP is as follows, with the PMB Code on the left and specific type of healthcare to be funded, indicated next to the code and diagnosis:

915 is the PMB Code, “… diabetes mellitus with peripheral circulatory disease” is the diagnosis and the minimum care is described in the last column as “medical and surgical management, including amputation”.

The PMBs also include the Chronic Disease List (CDL), which includes conditions, such as diabetes mellitus Type 1 & 2, hypertension (high blood pressure) and hyperlipidaemia (high cholesterol). Instead of a last column describing how it must be funded in general, these conditions are accompanied by “treatment algorithms”, published in the Government Gazette. 

A treatment algorithm is a step-by-step way in which a condition, such as diabetes, is to be treated. So, for example, for Type 2 diabetes, the algorithm says that one should start with lifestyle modification, and blood glucose monitoring is essential. Then, if the condition does not improve, the patient should go onto insulin. 

These algorithms are, however, not cast in stone, and deviations from it must, by law, be made under circumstances set out in the law. We will address these circumstances in the next article in this series.

Patients should not only understand when a condition is a PMB, but also how the treatment of that PMB condition is described.

Funded “in full” and “without co-payment or deductible”

Regulation 8(1) of the Medical Schemes Regulations, 1999 to the Medical Schemes Act of 1998 states that the PMBs: 

• on “any benefit option”;
• must be paid by the scheme “in full, without co-payment or the use of deductibles”;
• and they must pay for the “diagnosis, treatment and care costs.”

For any PMB, it is therefore not only the treatment that must be funded, but also the “diagnosis” and “care”: This includes diagnostic care, such as a glucometer and sufficient strips to ensure that blood glucose level testing can take place. Not paying for an adequate number of strips therefore violates the law.

“Care” includes, for example, feet care rendered by a podiatrist, that may become necessary due to diabetes that affects one’s arteries and circular system. 

Managing the cost of “funding in full”

The PMB law gives medical schemes two mechanisms to control the cost associated with the PMBs, namely (a) appointing designated service providers (DSPs) and (b) by implementation of managed care, such as setting medicines lists.

However, neither of these strategies (i.e. DSPs and managed care), are without limitations, and medical schemes can only use these strategies insofar as it is permitted by law. In the next article, we will address managed care.

The use of DSPs to render health services must be done in line with the law. There should be a formal contract between the service provider and the scheme, which sets out how the services are to be rendered, and what the scheme will pay the DSP. A scheme can, in its rules, say they will only fund a PMB condition or conditions in full, if the beneficiary obtains their healthcare from a DSP. If one freely chooses to not use the DSP, the scheme may impose a co-payment.

However, where one must go to the non-DSP, the scheme may not impose a co-payment. This means that there are exceptions to DSPs. These exceptions are called “involuntary visits to non-DSPs”:

• If the DSP was not available (e.g. one battles to get an appointment) or the service would not be provided without unreasonable delay (e.g. one must join a waiting list).
• If you required immediate treatment (e.g. in the event of a hypoglycaemic event that must be managed in hospital) and where the circumstances or the place where this happens means that one cannot get to the DSP.
• If the DSPs that the scheme has appointed, are too far from your home or work (e.g. you must travel far, or it is expensive, to get to the DSP).

What about choice?

It may seem that, although schemes must fund “in full” the PMBs, they have the power to limit the options and choices that patients have. In this regard regulation 8(5) is important, as it allows patients freedom of choice. The same as a patient can, at the payment of a co-pay, access even a non-DSP and exercise a free choice of a service provider (doctor, hospital, etc.), patients can also exercise choices in terms of treatment.

This part of the law allows patient to choose a medicine that is not on a scheme list. This may be where the patient wants to experience fewer side effects; have a specific preference for a specific product that they were on in the past; have other objectives, such as weight loss; or want to do fewer injections of medicine because of work or school obligations, and so on. This is a free choice, and is not necessitated by medical reasons.

In this case, the patient can decline the medicine that the scheme says it will fund in full, and fund an alternative medicine. So, the patient declines a medicine that they would have been okay on, in favour of something that satisfies other needs. In this case, the scheme may impose a co-payment on the patient. 

This co-payment, as is the case with all co-payments, must be reasonable. This means it must be “reasonable”, i.e. it cannot be exorbitant, and should be close to the real difference in cost.

The opposite of the above is also true: if the scheme medicine is inappropriate for the patient (e.g. the medicine on the list cannot be taken by the patient due to specific circumstances, e.g. pregnancy), the patient should not co-pay to access appropriate care.

Conclusion

Knowing whether your condition is a PMB is important. Also, complications that flow from PMB conditions must be funded. One should also know the rules around DSPs, and the exceptions to DSPs. Most importantly, one should know what the implications are of exercising a free choice, as opposed to choices that one must make on medical necessity.

MEET OUR EXPERT

Elsabė Klinck (B.Iuris, LLB, BA Hons (German), BA Applied Psychology) specialises in health law, -policy and -ethics. She owns a successful healthcare consulting firm, serving various clients in the pharmaceutical, medical device, healthcare professional and health facility markets.