Save thousands by understanding your right to medical benefit
The Council for Medical Schemes (CMS) 2008/9 Annual Report reveals there are 7 874 826 medical schemes beneficiaries in South Africa, spread among 119 medical schemes. Your editor – a principal member at the country’s largest open medical scheme – is one of these beneficiaries. Of course, things work perfectly with medical schemes until you need to claim from them. My doctor tried to explain why a textbook book length motivation wouldn’t be enough to get my medical scheme to pay for some essential dentistry: “You see – medical schemes are run like businesses,” began the familiar refrain.
The reluctance of medical aids to cover certain procedures led to the creation of a list of Prescribed Minimum Benefits (PMBs). The idea behind this list of minimum benefits is to ensure all medical scheme members have access to certain health services, regardless of the benefit option they have selected. One of the goals of the list is to provide people with continuous care to improve their health and well-being and to make healthcare more affordable.
What minimum benefits are prescribed?
Optivest Health Services recently distributed a press release asking whether a lack of knowledge regarding PMBs could result in medical schemes members paying for services the medical scheme should cover. Marcel du Toit, CEO of Optivest, says legislation is on your side; medical schemes need to pay for the diagnosis, treatment and care of the list of PMB conditions as compiled by the CMS. In 2008/9 the CMS announced penalties for schemes and administrators for non–compliance with PMB treatments and claim pay-outs!
As a minimum, medical schemes must cover the costs for the diagnosis, treatment and care of:
· Any emergency medical condition;
· A limited set of 271 medical conditions; and
· A set of 26 chronic conditions.
Know what you’re entitled to
The following example (provided courtesy of the CMS) illustrates how medical schemes might defer their PMB obligation:
Example - As simple as falling from a tree
When 11-year-old Johnny fell from a tree and fractured his left arm, his dad took him to their medical scheme’s DSP hospital.
The doctor on duty in the emergency room treated the fractured bone under local anaesthesia, applied a plaster cast and sent Johnny home with a prescription for pain tablets. The medical scheme informed Johnny’s dad that they were not going to pay the trauma facility accounts. In their opinion the member qualified for PMB services only if the person concerned was hospitalised.
Fortunately for Johnny’s dad, this is incorrect. PMB-related services are not restricted to a specific setting in which care should be provided. Therefore, PMB-related services can take place in the emergency room, at a clinic or in a GP’s rooms – in fact, wherever it is clinically appropriate.
“If you are worried about the cost of treatment, consult your medical aid broker or medical scheme, who will explain PMBs in detail,” says du Toit. “There are some rules the medical scheme can impose, like the service providers from whom you may obtain your medication – the Designated Service Providers (DSPs) – and chronic medication benefit programmes of which you should be part of.” It’s up to you to read the regulations and find out how your particular medical scheme applies them in practice.
A binding contract with your medical scheme
When you join a medical scheme you enter into a binding contract with the scheme. Optivest suggest you read all the fine print before signing, and that you read up as much as possible about PMBs, whether you choose the comprehensive or hospital plan option. Information is freely available from the CMS website (http://www.medicalschemes.com/).
The last word in the PMB debate hasn’t been had. Optivest notes that a task team has been established by the CMS and other stakeholders in the healthcare industry to establish a code of conduct – including how and why PMBs must be implemented. They add that the establishment of this team doesn’t mean the CMS will back down from its decision to penalise schemes and administrators for non-compliance.
Editor’s thoughts: There you have it. Your medical scheme is obliged to cover your treatment – subject to rules – for the emergency services, conditions and chronic ailments outlined in the PMB. Has your medical scheme forced payment for medical treatment of PMB conditions? Add your comment below, or send it to [email protected]
Comments