What Is PMB In Medical Terms

PMBs aim to provide people with quality, continuous healthcare and to improve their wellbeing. It also makes healthcare affordable. The PMB list allows all medical scheme members to access certain minimum health services regardless of their benefit choice. You can access PMBs regardless of whether you choose a hospital plan that is affordable or one with comprehensive benefits. There are also no exclusions for PMBs. If you have aesthetic surgery and contract septicaemia, then your healthcare scheme will be required to review the coverage for septicaemia as it could be related to PMBs. If necessary, extra clinical information can be used to determine if the claim is a PMB.

A Diagnosis-approach To PMBS

PMBs are defined by the fact that symptoms are more important than factors causing the symptom. The causes of symptoms that a doctor diagnoses are not important if the diagnosis is one of the 271 medical conditions listed or the 26 chronic conditions. What matters most is that the patient receives the right treatment for their condition.

Why Do We Have PMBS?

Medical schemes are required to cover costs associated with diagnosis, treatment and care of:

• Emergency medical conditions
• The Diagnosis Treatment Pairs (a limited set of 271 medical disorders)
• The Chronic Disease List includes 26 conditions.

The PMBs are caused by two main factors:

1. To ensure that medical scheme members, and their beneficiaries, have continuous coverage for PMBs even if they have exhausted their benefits for the year.
2. The Medical Schemes Act states that PMB must be covered even if the treatment is done at a public hospital.

There are also other reasons that PMBs are supportive of South Africa’s healthcare needs. They ensure that all people who need it have access to minimal healthcare, irrespective of their age, health status, or medical scheme coverage option. The PMBs are also important in ensuring that medical schemes stay financially sound. Members who receive quality healthcare will be healthier and less likely to develop serious illnesses that require expensive treatment.

What Conditions Are Covered Under PMBS?

In Annexure A of the Regulations for the Medical Schemes Act, there is a list of conditions that are identified as Prescribed Minimal Benefits. The list comes in the form Diagnosis and Treatment Pairs.

Here you can find a list of all 271 medical conditions as well as 26 chronic conditions.

A DTP ties a diagnosis to a particular treatment. Each of the 271 PMBs are paired with a general treatment plan that is based on proven healthcare and takes affordability into account.

Chronic medicine is used to treat and manage some of the conditions covered by the DTP, including TB, HIV infection and menopause management.

Your medical plan must cover all medication, doctor consultations and related tests if you suffer from one of the 26 chronic diseases listed. All of this is contained in the treatment plan that explains what services are available to members as part their chronic registration.

Making PMBS Work For You

You can see that PMBs grant medical scheme beneficiaries significant rights in terms of healthcare. It is up to you to make sure that PMBs are working as well as they should for you.

• Learn about the rules of your medical plan, as well as the medications and treatments listed for your condition.
• Find out which DSPs are covered by your plan and which medications are available for your condition.
• You must ensure that your chronic illness is covered by your medical plan.
• Check that your doctor has submitted a complete report to your medical plan and that it reflects the correct ICD-10 codes.
• Check that the account has been submitted and paid for within 30 days of receiving it. Medical schemes do not pay accounts older than 4 months.