Prescribed Minimum Benefits – South Africa

Information as at: 9 November 2009

References

Council for Medical Schemes: www.medicalschemes.com

Annexure A may be found at: (476k) http://www.medicalschemes.com/publications/ZipPublications/Acts%20and%20Regulations/GNR1262%20of%2020%20October%201999.pdf

Final Prescribed Minimum Benefits ICD 10 Five Character Coding – (Excel) Version 1.04: (1MB) http://www.medicalschemes.com/Publications/ZipPublications/Prescribed%20Minimum%20Benefits/PMB%205%20Character%20version%201.04%20MIT%20April%202008.xls

Discovery Health: www.discovery.co.za

Summary

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 these from the risk benefits and not from a member’s day-to-day benefits.

The Council for Medical Schemes introduced the Prescribed Minimum Benefits in 2000 to define minimum levels of cover. These minimum benefits are a safety net and ensure that members aren’t without care for certain major medical expenses because they cannot afford it.

The aims of the Prescribed Minimum Benefits are to:

• Ensure that members are able to gain access to care for the Prescribed Minimum Benefits without financial obstacles when treatment is accessed at the Designated Service Provider
• Contain cost of healthcare by allowing the scheme to appoint the Designated Service Provider; where a DSP is unable to accommodate or treat a member, the medical scheme remains liable for the full costs of the PMBs, and
• Encourage more efficient use of private and public healthcare resources

Important explanatory notes

(3) “Treatable” cancers.—In general, solid organ malignant tumours (excluding lymphomas) will be regarded as treatable where:

1. they involve only the organ of origin, and have not spread to adjacent organs
2. there is no evidence of distant metastatic spread
3. they have not, by means of compression, infarction, or other means, brought about irreversible and irreparable damage to the organ within which they originated (for example brain stem compression caused by a cerebral tumour) or another vital organ
4. or, if points (i) to (iii) do not apply, there is a well demonstrated five-year survival rate of greater than 10% for the given therapy for the condition concerned.

PMB categories

The Prescribed Minimum Benefits can be classified under three categories:

1. Emergency condition (any emergency)

2. Diagnostic Treatment Pairs (270 conditions)

3. Chronic Disease List (27 chronic conditions including HIV and AIDS)

Emergency medical conditions

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.

Diagnostic Treatment Pairs

The diagnosis and treatment of conditions that are related to Prescribed Minimum Benefits consists of Diagnostic Treatment Pairs. This refers to a diagnosis linked to a procedure.

There are about 270 treatment pairs that cover serious and acute medical problems that include the cost of diagnosis, treatment and care of these conditions as set out by the Council for Medical Schemes.

The Prescribed Minimum Benefits were defined according to a specific set of principles to protect members in the case of serious illnesses. The Council for Medical Schemes considered the following issues when they defined them:

• The cost-effectiveness of the treatment or procedure (state guidelines are used to determine this)
• The availability of the type of treatment in a state facility as the minimum cost intervention the scheme should offer.

A list of these conditions can be obtained from the Council for Medical Schemes’ website: www.medicalschemes.com

Chronic Disease List

The Chronic Disease List provides cover for chronic medicines for the 27 listed chronic conditions, including HIV and AIDS.

The Prescribed Minimum Benefits require medical schemes to cover the diagnosis, medical management and medicine for a specified list of 27 chronic conditions known as the Chronic Disease List.

1. Addison’s disease
2. Asthma
3. Bipolar mood disorder
4. Bronchiectasis
5. Cardiac failure
6. Cardiomyopathy
7. Chronic renal disease
8. COPD – chronic obstructive pulmonary disease
9. Coronary artery disease
10. Crohn’s disease
11. Diabetes insipidus
12. Diabetes mellitus type 1
13. Diabetes mellitus type 2
14. Dysrhythmias
15. Epilepsy
16. Glaucoma
17. Haemophilia
18. Hyperlipidaemia (high cholesterol)
19. Hypertension
20. Hypothyroidism
21. Multiple sclerosis
22. Parkinson’s disease
23. Rheumatoid arthritis
24. Schizophrenia
25. Systemic lupus erythematosus
26. Ulcerative colitis
27. HIV and AIDS

Council for Medical Schemes

www.medicalschemes.com

The Council for Medical Schemes is a statutory body established by the Medical Schemes Act (131 of 1998) to provide regulatory supervision of private health financing through medical schemes.

The governance of the Council is vested in a board appointed by the Minister of Health, consisting of a Non-executive Chairman, Deputy Chairman and 13 members. The Executive Head of the Council is the Registrar, also appointed by the Minister in terms of the Medical Schemes Act. The Council determines overall policy, but day to day decisions and management of staff are the responsibility of the Registrar and the Executive Managers.

MINIMUM BENEFITS, WAITING PERIODS AND LATE JOINER PENALTY

Q26. What are prescribed minimum benefits (PMBs)?

The benefits in respect of relevant health services prescribed by the regulations under the Act, and rendered by State hospitals or designated service provider according to clinical protocols and criteria.

Q27. What is a designated service provider (DSP?)

A healthcare provider or group of providers selected by the scheme as the preferred provider or providers to provide to its members diagnosis, treatment and care in respect of one or more prescribed minimum benefit conditions.

Q28. To what extent are the prescribed minimum benefits restricted?

No restrictions, co-payments, waiting periods or exclusions may be applied to any person in respect of the prescribed minimum benefits if the services are rendered by State hospitals or DSPs. In instances where services are voluntarily obtained from a non – DSP, co – payments may apply or waiting periods may be imposed only on those applicants who have never belonged to a medical scheme, or have not been beneficiaries for the preceding 90 days.

Q29. What constitutes the involuntary obtaining of services in respect of the PMBs from non – DSPs?

Involuntary obtained means:

• 1. the service was not available from the designated service provider or would not be provided without unreasonable delay;

• 2. immediate medical or surgical treatment for prescribed minimum benefit condition was required under circumstances or at locations which reasonably precluded the beneficiary from obtaining such treatment from a designated service provider; or

• 3. There was no designated service provider within reasonable proximity to the beneficiary’s ordinary place of business or personal residence.

Q30. What are the types of waiting periods?

There are two kinds of waiting periods i.e.:

1. General waiting period of up to three months.

2. Condition-specific waiting period of up to 12 months.

Q31. What does a waiting period mean?

A period during which contributions are payable without the member being entitled to benefits.

Q32. When do waiting periods not apply?

Waiting periods do not apply in respect of:

• 1. Prescribed minimum benefits other than specified in Q28

• 2. A child dependant born during the period of membership

• 3. A member moving between benefit options unless he has to complete the remaining period of previously imposed waiting periods.

• 4. When an individual has to involuntarily transfer to another scheme due to a change of employment.

• 5. In instances where an employer changes the medical scheme of hisemployees with effect from the beginning of the financial year.

Q33. How can I prove to a new scheme that I was a member of another scheme?

A scheme must within 30 days of termination of membership, or at any time at the request of a former member, or of a dependant of a member, provide such person with a membership certificate stating the period of cover and other prescribed information. The applicant is also entitled to produce a sworn affidavit in those instances where reasonable efforts to obtain documentary evidence of previous membership were unsuccessful.

Q34. What is a late joiner penalty?

It is a penalty by way of additional contributions, imposed on persons joining a scheme late in life i.e. an applicant who is 35 years of age or older who was not a member of one or more medical schemes as from a date preceding 01 April 2001 without a break in coverage exceeding three consecutive months since 01 April 2001.

Q35. What restrictions may a medical scheme impose on an applicant?

• 1. Late joiner penalty

• 2. Waiting periods

Q36. Can a medical scheme impose a condition – specific waiting period on    pregnancy?

Yes, in those instances where the person was a beneficiary of a medical scheme for up to 24 months

Discovery Health

www.discovery.co.za

The Prescribed Minimum Benefits can be classified under three categories:

1. Emergency condition (any emergency)
2. Diagnostic Treatment Pairs (270 conditions)
3. Chronic Disease List (27 chronic conditions including HIV and AIDS)

1. Emergency medical conditions

Definition of an 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.

Funding of an emergency admission

The Discovery Health Medical Scheme will pay the conditions that are defined on our emergency list in full. We will fund an emergency admission into any hospital at cost for the number of emergency days approved. Once the member is stable and if the hospital or healthcare provider is not one of our DSPs, we will assist the member to transfer to a DSP. However, we will apply our “non-DSP” rules if the member continues receiving treatment from the non-DSP provider once they are stable.

Transferring members to a Designated Service Provider

Members have the choice to transfer to a DSP facility or provider, or may choose to remain in the non-DSP hospital and with the same healthcare provider. If the member chooses to be transferred to a DSP, Discovery Health will arrange and fund the transfer as soon as it is clinically safe to do so. If the member chooses to stay on in the non-DSP facility, we will then pay the hospital and related provider accounts at 60% of the Discovery Health Rate and the member will be responsible for the shortfall, as a co-payment.

1. Diagnostic Treatment Pairs

The diagnosis and treatment of conditions that are related to Prescribed Minimum Benefits consists of Diagnostic Treatment Pairs. This refers to a diagnosis linked to a procedure.

There are about 270 treatment pairs that cover serious and acute medical problems that include the cost of diagnosis, treatment and care of these conditions as set out by the Council for Medical Schemes.

The Prescribed Minimum Benefits were defined according to a specific set of principles to protect members in the case of serious illnesses. The Council for Medical Schemes considered the following issues when they defined them:

• • The cost-effectiveness of the treatment or procedure (state guidelines are used to determine this)
  • The availability of the type of treatment in a state facility as the minimum cost intervention the scheme should offer.

A list of these conditions can be obtained from the Council for Medical Schemes’ website: www.medicalschemes.com

Applying for cover for the Diagnostic Treatment Pairs

Members need to apply for a claim to be paid as a Prescribed Minimum Benefit, preferably before the actual event or treatment (or both). We will assess the application against our clinical entry criteria, which guides our funding decision. Based on the information provided, we can communicate to the member how we will pay the claims: either in full, or part payment.

Hospitalisation for Diagnostic Treatment Pairs (DTP)

Members need to follow the normal hospital benefit confirmation process by calling Discovery Health on 0860 99 88 77

Out-of-hospital management of Diagnostic Treatment Pairs

Members need to send us a completed out-patient PMB application form PMB out-patient application form

Oncology

Members need to send us a completed oncology application form Oncology application form.

Diagnostic tests for a confirmed PMB diagnosis

The Prescribed Minimum Benefits will apply where members develop symptoms and seek help from healthcare professionals for appropriate tests to make a positive diagnosis. Patients could also use screening tests to determine a non-symptomatic diagnosis, for example high blood pressure and high cholesterol.

We can only pay these diagnostic claims after we’ve received the results. This is because we need a positive diagnosis to determine if the condition is a Prescribed Minimum Benefit condition.

We will consider paying claims for medical expenses up to 120 days before the date when the diagnosis as a Prescribed Minimum Benefit was made.

How to claim from the Prescribed Minimum Benefits for diagnostic tests

This process should also be followed for consultations with the member’s doctor.  We can only evaluate whether the test or consultation can be covered as a PMB retrospectively.

What the member needs to do

1. 1. Complete the Out-patient Prescribed Minimum Benefits form
   2. Attach the claim(s) for the diagnostic test(s) to the form. The claim must contain the      relevant ICD-10 code. This helps us to identify the claims that can be paid as Prescribed Minimum Benefits.
   3. Send the form to us at the address on the form.

By not following this process and including all the information, means we are unable to identify the claim as a Prescribed Minimum Benefit claim. We will therefore process the claim as a normal claim through the day-to-day benefits (Medical Savings Account and Above Threshold Benefit) subject to the plan type and the availability of funds and benefits.

Chronic Disease List

The Chronic Disease List provides cover for chronic medicines for the 27 listed chronic conditions, including HIV and AIDS.

The Prescribed Minimum Benefits require medical schemes to cover the diagnosis, medical management and medicine for a specified list of 27 chronic conditions known as the Chronic Disease List. These conditions are covered on all Discovery Health Plan types: