Managed Healthcare Systems Authorisation programmes and Claims - - PDF document

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Managed Healthcare Systems Authorisation programmes and Claims Management

Member Information: Prescribed Minimum Benefits (PMB)

Prescribed Minimum Benefits (PMBs): - Is a set of minimum benefits which, by law, must be provided to all medical scheme members and include the provision of diagnosis, treatment and costs of on-going care. Each PMB condition may be related to at least one PMB group code of which the minimum level of care is stipulated.

• 1. Understanding what the Prescribed Minimum Benefits are:

Prescribed Minimum Benefits 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 limited set of 270 conditions as specified in Annexure A of the Regulations to

the Medical Schemes Act (No 131 of 1998);

• Any emergency condition; and
• A list of 27 chronic conditions including HIV and AIDS.

Medical schemes have to pay for these conditions at least to the level of care or treatment provided in the public sector. These conditions may not be paid for from the member’s MSA.

• 2. PMB Chronic Conditions

The Chronic Disease List (CDL) specifies medication and treatment for the 27 chronic conditions that are covered in this section of the PMBs: The conditions are as follows:

• Addison's disease;
• Asthma;
• Bronchiectasis;
• Cardiac failure;
• Cardiomyopathy;

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• Chronic obstructive pulmonary disorder;
• Chronic renal disease;
• Coronary artery disease;
• Crohn's disease;
• Diabetes insipidus;
• Diabetes mellitus types 1 & 2;
• Dysrhythmias;
• Epilepsy;
• Glaucoma;
• Haemophilia;
• Hyperlipidaemia;
• Hypertension;
• Hypothyroidism;
• Multiple sclerosis;
• Parkinson's disease;
• Rheumatoid arthritis;
• Schizophrenia;
• Systemic lupus erythematosus;
• Ulcerative colitis;
• Bipolar Mood Disorder;
• HIV; and
• AIDS.

To manage risk and ensure appropriate standards of healthcare, so-called treatment algorithms were developed for the CDL conditions. There are also clinical entry criteria which will allow the member to register their PMB chronic disease with the medical scheme to ensure correct payment of benefits. Some medical schemes will require the member to enrol on their disease management programmes or PMB care plans for certain of the above chronic diseases to ensure a full set

• f benefits.

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• 3. Set of 270 PMB conditions:

These PMB’s ensure that medical scheme beneficiaries have access to on-going treatment for clinically diagnosed PMB conditions. The treatment of these conditions is funded in line with clinical guidelines, protocols, formularies and according to clinical necessity. Medical scheme members with PMB conditions are entitled to the specified treatment of their conditions, which must be funded by their medical scheme at least to the level of that which is provided in the public sector. As an example: The member has appendicitis; this condition will fall under PMB group 9F. The requirement is:

9F Appendicitis Appendectomy

The scheme thus needs to fund the treatment and care of an appendectomy in full. However: The scheme is not obliged to fund a laparoscopic approach or Ligasure instrument should these be excluded in terms of the managed care protocol or exclusion guideline.

• 4. Emergency Conditions:

Emergency Medical Admission: According to the Medical Scheme Act, An emergency medical condition 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.