What are the PMBs?
THE PMBS ARE BENEFITS ALL MEDICAL SCHEMES
have to provide, by law, regardless of the option you choose to join.  

PMBs cover treatment, diagnosis and care for:

• Any emergency medical condition;
• 270 medical conditions  most are life-threatening ones that require treatment in hospital, but the PMBs also include some urgent care for non-life- threatening conditions, maternity care and palliative (pain-relieving) care for the terminally ill; and
• About 25 common chronic conditions,  ones for which you are likely to need ongoing medication and consultations with your doctor.

Medical schemes are governed by the Medical Schemes Act. The Act states that all schemes have to provide certain benefits, which are determined by the Minister of Health. The medical conditions for which benefits must be provided are in fact contained in the regulations under the Medical Schemes Act.  You will find a copy of these regulations on the Council for Medical Schemes’s website at www.medicalschemes.com in the Publications section under the heading “Acts and regulations”.

The Act refers to 270 medical conditions covered by the PMB’s including hospital management of various mental disorders, such as the initial diagnosis of treatable dementia and the management of acute psychotic symptoms.

1.  There cannot be any exclusions
YOUR MEDICAL SCHEME ALWAYS HAS TO PAY FOR
the PMBs and there can’t be any exclusions.

According to the Council for Medical Schemes your scheme may, for example, exclude cover for cosmetic surgery, which is not a PMB. But if you contract septicaemia, which is a PMB condition, after cosmetic surgery, your scheme will have to pay for you to be treated for that septicaemia. PMBs are concerned about the diagnosis; it doesn’t mailer how you got the condition.

2.  You may have to use certain providers
The law allows schemes to insist that you use certain healthcare providers to access the PMBs.

For example, your scheme may insist that you use certain pharmacies to obtain your chronic medication, con- suit certain doctors for the diagnosis of a PMB or be admitted to certain hospitals for PMB treatment. These healthcare providers are referred to as the scheme’s designated service providers (DSP).

Your medical scheme should make sure you are aware that it has contractually appointed a DSP and must keep you abreast of any changes to its DSPs.

3.  What if you choose not to use the DSP?
IF YOU DO NOT WANT TO USE THE DSP YOUR scheme has chosen, you can use another provider, but in this case your scheme does not have to pay in full for the diagnosis, treatment or care of your PMB condition. It can’t refuse to pay the bill at all, but it can impose a reasonable co-payment.

There are two ways in which a medical scheme can impose a co-payment:

• Bill you for the difference between the actual charge and what it would have paid for the medical service in respect of a PMB if you had used its DSP; or
• Charge you a percentage of the cost of the service as a co-payment. For example, a scheme can state that if you do not use its DSP, you will have to pay 20 percent of the cost as a co-payment.

4.  Full cover without using a DSP
THERE ARE TIMES WHEN YOU’RE SCHEME WILL have to cover the treatment you obtained, even though you have not used a DSP.

Regulations under the Medical Schemes Act provide for instances in which it is not possible for you to use a DSP for the diagnosis, treatment or care of a PMB condition. For example, if you need treatment for a PMB condition very urgently and you aren’t able to get rapidly to the hospital that has been named as the DSP, and, as a result, you use a non-DSP hospital, you will be regarded as having obtained the service involuntarily and your scheme will have to pay.

The three cases in which you will be regarded as having obtained the service involuntarily are:
• If the service was not available from the DSP or could not be provided without unreasonable delay;
• If there was no DSP within reasonable proximity of your place of work or residence; or
• If you needed immediate treatment under circumstances that prevented you from using the DSP.

5.  Herewith all the PMB conditions pertaining to Mental Health

According to:  Regulations in terms the Medical Schemes Act, 1998 (Act No. 131 of 1998).