Category Healthcare
SUB CATEGORIES General  |  HIV |  Medical Schemes | 

Medical Aids have PMBs, so why do I need Gap Cover?

29 August 2019 Tony Singleton, CEO of Turnberry Management Risk Solutions
Tony Singleton, CEO of Turnberry Management Risk Solutions

Tony Singleton, CEO of Turnberry Management Risk Solutions

All Medical Aids fall under the Medical Scheme Act 131 of 1998, which legislates that a list of 270 Prescribed Minimum Benefits (PMBs) must be covered in full, however, this is subject to terms and conditions. So, why do you still need gap cover, if you will be fully covered? The reality is that PMBs are more complicated than just a list of medical conditions. It means that even if you are diagnosed with a PMB you might still be in for a co-payment surprise. Moreover, the list is by no means exhaustive, and there are many conditions that fall outside of this list. As a result, Gap Cover is still your best defence to avoid large and unexpected medical expense shortfalls from causing financial distress.

PMBs have specific diagnosis treatments
According to the Council of Medical Schemes, PMB coverage has been written into law to ensure that all members of medical schemes have access to certain minimum health services, regardless of the medical scheme benefit option they have selected. Moreover, PMBs form part of the Medical Schemes Act and stipulate what costs schemes must cover relating to diagnosis, treatment and care of any emergency medical conditions, a limited set of 270 medical conditions and 25 chronic conditions.

However, what many people fail to understand is that the PMB conditions are listed as Diagnosis Treatment Pairs where a diagnosis is paired with specified treatment. For instance, for Diagnosis Treatment Pair 9F the diagnosis is Appendicitis and specified treatment is an Appendectomy. Therefore, if you are admitted to hospital for Appendicitis and the treatment plan is administration of antibiotics only it would not be considered PMB level of care. So, if your condition is a PMB, but the treatment proposed by your doctor includes treatment that is not specified for that specific Diagnosis Treatment Pair, it may not be covered in full.

In addition, the level of care also needs to be available in the public sector. For example, if you are diagnosed with a specific cancer that meets PMB diagnosis criteria, this will be covered in full if the specified treatment at a DSP is based on the guidelines and treatment protocols as per the public sector. However, your doctor may propose biological cancer drugs as part of your treatment. Unfortunately, these specific drugs may not be currently offered in the public sector. and your treatment will not be covered as a PMB leaving you liable for any payments outside of what your medical scheme plan offers.

Cover at non-DSPs is not guaranteed
In the case of an emergency, a PMB will be covered at the closest available facility even if this is not a Designated Service Provider (DSP). However it is important to understand how the regulations define an emergency medical condition. According to the law it is “the sudden and, at the time, unexpected onset of a health condition that requires immediate medical or surgical treatment, where failure to provide medical or surgical treatment would result in serious impairment to bodily functions or serious dysfunction of a bodily organ or part, or would place the person’s life in serious jeopardy.” For example, if you break your leg and the bone has ruptured the skin, and you go to the emergency room, the doctor and orthopaedic surgeon may not be DSPs and may charge above the scheme rate, but in this instance they will be covered in full. Once your condition no longer constitutes an emergency, however, treatment at the non-DSP may not be fully covered.

In addition, if you elect to be treated by a non-DSP in the case of a diagnosed PMB condition that is a planned procedure and not a life-threatening emergency, your medical scheme may still impose a co-payment. PMBs at a non-DSP will only be covered in case of emergency, as previously described, or the cases where a DSP is unable to assist within a reasonable time frame. This second instance includes cases where immediate medical or surgical treatment for a PMB condition is required and there is no designated service provider within reasonable proximity to the beneficiary’s ordinary place of business or personal residence.

There’s a difference between medical schemes and health insurance
People need to remember or rather understand that there is a difference between low cost health insurance options and medical schemes. The major difference is that health insurance falls under the Short-Term Insurance Act, not the Medical Schemes Act. This means that they do not have to comply with the list of PMBs, which are only applicable to medical schemes.

How can gap cover help?
Firstly, your condition or diagnosis may not even fall within the list of PMBs, and in this case you will be liable for any medical expense shortfalls over and above the scheme rate at a DSP. Gap cover can help to lessen the financial burden.

If you do have a PMB condition, the treatment you receive needs to match the specified treatment stipulated for that Diagnosis Treatment Pair and the level of care needs to be what is available in the public sector and you need to make use of a DSP for planned procedures in order to get the account paid in full at cost. These are a lot of conditions to comply with in order to get payment in full. If you do not meet the aforementioned criteria then the medical scheme is not obliged to pay your claim in full, and gap cover can help to cover these medical expense shortfalls.

In order to have conditions funded as PMBs you may also need to provide supporting evidence to the medical aid, and a gap cover provider can assist with this. Your gap cover provider will also check any claims you make with them to see whether medical aids should have regarded the claim as a PMB, to ensure that you obtain the highest level of cover possible before leaning on gap cover.

It’s about protecting your financial future
Not every condition is a PMB, which means that there could be significant additional expenses attached. Even when PMB conditions are diagnosed, the treatment proposed may not be fully covered. Medical expense shortfalls can ruin families if you do not have gap cover in place. Gap cover is the most cost effective way to protect your financial future from significant medical bills that could financially cripple you for years to come.


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