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April 10 2011 at 12:40pm
By Laura du Preez

Eleven years after the Medical Schemes Act introduced the prescribed minimum benefits (PMBs) to ensure that you receive essential treatment for medical emergencies and illnesses that threaten the quality of your life, these benefits are still mired in controversy and confusion.

The PMBs:

* Are the subject of a court case over how they should be interpreted;

* Have been blamed as the major driver of the cost of medical scheme cover; and

* Are widely misunderstood by medical scheme members.

In the meantime, work is progressing on projects to ensure there is greater clarity about the benefits to which you are entitled and when you are entitled to claim them, as well as to inform you of your rights (see “Definitions will clarify how you should be treated”, below).

A major court case that pits medical schemes against healthcare providers is playing out in the North Gauteng High Court. Schemes, the Council for Medical Schemes and providers are arguing over whether regulations under the Medical Schemes Act mean that the PMBs should be paid at scheme rates or at whatever rate a provider charges. Final papers have been filed in the case, which is expected to be heard in the next two months.

Schemes represented by the Board of Healthcare Funders are challenging the Council for Medical Schemes’ view that the PMBs must be paid at the rates at which providers invoice schemes.

The schemes believe that if they could pay claims at the rates they set, they will be able to contain the cost of claims, and hence your contributions, better.

The court case may provide some evidence on whether or not the PMBs are to blame for rising member contributions.

Meanwhile, a recent survey by Old Mutual Actuaries & Consultants (Omac) has found that medical schemes, employers that subsidise their employees’ scheme contributions and brokers all regard the PMBs as the biggest driver of medical scheme costs – and containing these costs is their biggest concern.

The survey highlights an alarming ignorance of the PMBs among medical scheme members and a lack of appreciation for the protection that these benefits offer them. Only 15 percent of the members surveyed understood the PMBs, while only 19 percent of the schemes surveyed said their members understood the PMBs.

Margaret Hulme, the head of healthcare consulting at Omac, says that medical scheme members generally do not understand their PMB entitlements, nor do they know where or how to access their benefits, and, as a result, they do not appreciate the PMBs. The survey found that members who need or use the PMBs have a greater understanding of them.

The findings show that schemes do not apply the PMBs uniformly, which adds to members’ confusion, Hulme says.

Closed schemes, the survey found, generally are more lenient when it comes to the PMBs and implement fewer of the control measures that are allowed by law.

Closed schemes could tighten up on the provision of PMBs, and this would reduce their costs, the survey says.

While confusion reigns over the interpretation of the PMB regulations, and the benefits remain ill-defined and information is scant, your best defence as a member of a medical scheme is to be as informed as you can and to ask as many questions as possible.

The law is on your side, but your ignorance of it could thwart your attempts to have your PMB claims paid. You need to ensure that:

* You are not paying for claims that should be paid by your scheme;

* Your scheme is not paying your PMB claims out of your medical savings account;

* You are not losing out on treatment to which you are entitled; and

* You are not resorting to using state facilities when you should be covered for treatment in the private sector.

Because they are unaware of their rights, many people give up after their scheme rejects their claim or pays it from their medical savings account.

However, large medical schemes have told Personal Finance that their administration systems are sometimes unable to identify PMBs, resulting in claims being rejected when they should not be.

Personal Finance has also come across cases where administration systems have failed to pay legitimate claims and cases where schemes have incorrectly stated that the PMBs do not extend to a treatment.

Your doctor should know the conditions for which schemes must provide benefits, but practitioners are often vague about your rights, saying only that the scheme should cover the treatment.

They may not be familiar with the rules of your scheme or the procedures your scheme expects you to follow to qualify for the PMBs. Often, schemes do not communicate these procedures well, or, as the Omac survey found, members often do not read the information that their scheme sends them.

Personal Finance canvassed six large open medical schemes on how they deal with PMB claims. We found that they follow a confusing array of procedures: at times your claim may be identified and paid automatically, but at other times you may be expected to follow some kind of authorisation process.

A Cape Town endocrinologist treats mostly diabetes and thyroid patients. Diabetes type 1 and 2, and hypothyroidism are among the common chronic conditions that are listed as PMBs. Hyperthyroidism is also a PMB.

However, the specialist says that many of his patients consult him until the funds in their medical savings accounts run out. One patient even made use of state facilities after her savings account was depleted. These members are not aware that their treatment should be paid for by the scheme and not from their medical savings accounts. Their benefits should not run out at all during the year for PMB treatment.

WHAT ARE THE PMBs?

The prescribed minimum benefits (PMBs) cover a range of medical conditions, from emergencies to illnesses, that if left untreated would negatively affect the quality of your life.

The PMBs include 27 common chronic conditions, such as high blood pressure, cholesterol and diabetes.

By law, your medical scheme has to pay for your claims for the diagnosis of, and the consultations or treatment related to, a PMB. None of these claims may be paid from your medical savings account even if you have funds in the account.

However, to contain the cost of providing the PMBs, medical schemes are allowed to name a designated service provider (DSP) that you must use for any tests, consultations, medication, other treatment or hospital admission (except in an emergency or if the DSP is not available).

Medical schemes are also entitled to limit the benefit to the treatment you would receive if you were treated at a state clinic or hospital.

They are also allowed to make you jump through some administrative hoops to obtain treatment. For example, you may have to obtain pre-authorisation, join a scheme’s disease management programme, or complete a chronic medication application form annually or when your doctor recommends a change in medication.

DEFINITIONS WILL CLARIFY HOW YOU SHOULD BE TREATED

The first six of a number of definitions that will provide greater clarity on the medical services to which you are entitled when you have a condition covered by the prescribed minimum benefits (PMBs) will be published this year. This is according to the Council for Medical Schemes, which is leading a process to define the PMBs.

Last year, the council, medical schemes and their administrators, and healthcare providers signed a PMB code of conduct in terms of which the parties agreed to ensure that you, the scheme member, will have better access to the PMBs.

One of the measures to which they agreed was to define the PMBs in simple language that will clarify:

* When a medical condition is regarded as a PMB;

* What diagnoses or tests need to be carried out to verify that your medical condition is in fact a PMB; and

* The services, care (including the level of care), medicines and devices for which you can expect your scheme to pay should you have a PMB condition.

The Medical Schemes Act and its regulations state that schemes must pay for the diagnosis, treatment and care of PMB conditions in line with the prevailing practice in state healthcare facilities.

At times it is difficult to determine what the prevailing practices are in state facilities or to align private sector practices with them.

Treatment algorithms, which outline the minimum standards of treatment, are available for only the 27 common chronic conditions covered by the PMBs.

Boshoff Steenekamp, who is leading the PMB code and definitions projects at the Council for Medical Schemes, says that definitions of six high-cost conditions where uncertainty about the benefits has a high impact on people’s lives will be published for comment this year before being fined-tuned.

Last year, numerous consultative meetings were held with schemes, patient groups and clinicians, and work was started on other PMB definitions as well, Steenekamp says.

The Council for Medical Schemes and clinical advisory committees considered benefit definitions for transplants in general; heart, liver and kidney transplants; the treatment of certain cancers, including breast, prostate and gastro-intestinal cancers; and cardiovascular conditions.

Another issue that the council, schemes, administrators and providers agreed to tackle is the information you must be given about the PMBs. The code of conduct commits schemes to providing you with pertinent information about the PMBs, in plain language, when you join a scheme.

In addition, the code commits the Council for Medical Schemes to leading a process to establish guidelines for the communication of information about the PMBs.

The process to establish the communication guidelines will start this financial year, Steenekamp says.

Remember: The PMB code of conduct commits a medical scheme to reassess a PMB claim up to three years after the scheme processed it if you later establish that the condition for which you claimed is a PMB but your scheme did not have sufficient information to identify it as such


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