If you’re a member of a medical scheme, you should know about Prescribed Minimum Benefits (PMBs). These are the benefits that are, by law, offered to ALL medical scheme members, no matter the scheme and guarantee access and cover to a minimum defined list of benefits.
The intention is to ensure all members of medical schemes in South Africa have access to essential treatment for certain, pre-determined, medical conditions. In theory, they provide a safety net, guaranteeing a minimum level of care for serious illnesses like cancer. Sounds good, right?
In practice, the cost of PMBs has been on the rise and recent estimates by healthcare acturaries indicate that this set of benefits costs close to R2 000 per beneficiary per month. Since medical schemes are legally required to offer them, this shoots up the cost of premiums to a level many cannot afford. Essentially, PMBs are meant to protect members, but they should also keep private healthcare accessible.
The various debates regarding Low Cost Benefit Options (LCBO’s) similar to health insurance products, effectively requires the medical schemes regulator to provide an exemption to schemes to compete with health insurance products which offer cover well below that of PMB’s and are often regarded as more affordable than medical schemes.
Despite the lack of concessions regarding PMB’s when choosing between a health insurance product and a medical schemes product, the benefits provided by PMB’s should assure a consumer that they have far better cover than the typical health insurance product.
PMB’s are often mistaken for full cover or maximum benefit and so medical scheme members must take note that as the wording suggested even if your condition is classified as a PMB, not all the treatment is necessarily covered only basic lifesaving treatment.
Algorithms within the regulations define the level of treatment you receive within a PMB – determining what must be treated surgically or medically. Even though you may have cancer, you could feel entitled to only the best treatment possible. That expectation is incorrect.
You’ve all heard about the cost of cancer treatment. Typically, drugs called biologics used for treatment, but they don’t fall under a PMB level of care. Your cancer might require surgery and medication, but biologics are not included – which could save your life. In these cases buying a more comprehensive medical scheme option may cover some biologics depending on the benefits of that option.
Patients may feel that biologics are essential, and oncologists might recommend them as the only thing that will control the cancer. But biologics are expensive and are not included in a PMB level of care. This is why discussions about maximum versus minimum benefit are often so difficult.
To help navigate these complexities, specialised oncology-trained nurses engage with oncologists, supporting and helping members draw up treatment plans to manage PMBs and other costs. This additional healthcare coach provides critical support for members facing serious conditions.
The PMB framework needs urgent review to consider the relevance of the set of benefits now more than 20 years old. It absolutely needs a proper overall review. Regulators have spoken in recent years, and in line with the NHI agenda, there is discussion about introducing a primary healthcare package as part of PMBs. The current set of PMBs do not to include primary or preventative care and are subsequent to a diagnosis. There is an ongoing effort and debate on incorporating primary care or preventative care benefits into PMBs, and medical schemes are happy to support that where costs are also carefully conidered.
As a scheme, we have applied to the Regulator to provide for low-cost benefit options which would open up affordability to graduates who are starting their businesses and are concerned about the cost of premiums. An effective LCBO would effectively exempt members from PMBs while still providing coverage relevant to their needs and affordability.
PMBs have their place, and they are important. But currently, they can make healthcare less accessible and more expensive. Not only that, they create confusion for members, especially when it comes to expectations for treatment and coverage.
Even though you may have cancer or some other disease, you need to be aware of what treatment your medical scheme will cover. Individual cases are evaluated carefully, and this is why ongoing support and engagement are so important.
PMBs were designed to protect members and provide a minimum standard of care, but in their current form, they also drive up costs while limiting access to private healthcare. Every medical scheme member needs to understand what PMBs cover and what they don’t. At the same time, the system itself requires urgent review to keep pace with modern healthcare needs. Mostly, it should be geared to ensure that PMBs continue to serve the people they were meant to protect. Until that happens, ongoing support, careful planning, and clear communication remain critical if the country is going to get the most value out of the PMB system.
Written by Profmed CEO, Craig Comrie