Prescribed Minimum Benefits
Definition of terms
Prescribed Minimum Benefits (PMBs) - 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 ongoing care.
Designated Service Provider (DSP) - a healthcare provider or group of healthcare providers (facility and professionals) who have a payment agreement with a medical scheme.
Chronic Illness Benefit (CIB) - covers the diagnosis, medical management and medicine to the extent that it is provided for in terms of a therapeutic algorithm as prescribed for 27 chronic conditions, including HIV and AIDS.
Introduction
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 these from the risk benefits and not from a member's day-to-day benefits.
How the Prescribed Minimum Benefits came about
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.
What the Prescribed Minimum Benefits aim to achieve
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.
When a member will be eligible for Prescribed Minimum Benefits
The Discovery Health Medical Scheme will only make a payment that is solely for Prescribed Minimum Benefits when the healthcare provider uses an ICD-10 code (diagnostic code) that corresponds to the list published by the Council for Medical Schemes.
A list of these conditions can be obtained from the Council for Medical Schemes’ website: www.medicalschemes.com
Not all Discovery Health members have access to Prescribed Minimum Benefits
Members who've never belonged to a medical scheme or allowed a break in membership of more than 90 days won't have access to PMBs during either a three-month general waiting period and/or 12-month waiting period on pre-existing conditions. This includes emergency admissions during the three-month general waiting period. We refer to these members as Category A members.
Level of cover and cost implications
What the Medical Schemes Act says about the extent or level of cover
Section 29 of the Act makes schemes set out the "scope and level of minimum benefits" in its rules. Section 31 makes the scheme ensure that its benefit options are financially sound. This means that a medical scheme should provide at least the minimum level of cover for Prescribed Minimum Benefit conditions. The State/Public sector guidelines are used as a minimum bases for cover. Excessive exposure would threaten the financial viability of the scheme, placing the membership base in jeopardy.
Medical schemes may use risk management tools
Medical schemes may use risk management tools to ensure that cover is appropriate and cost-effective. Some of these tools are:
- formularies or medicine lists
- treatment protocols that include clinical entry criteria (diagnostic or laboratory tests confirming the diagnosis)
- treatment algorithms
- benefit confirmation for procedures, and
- designated service providers.
Classification of Prescribed Minimum Benefit categories
The Prescribed Minimum Benefits can be classified under three categories:
- Emergency condition (any emergency)
- Diagnostic Treatment Pairs (270 conditions)
- 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 non-DSP related providers accounts at 80% of the Discovery Health Rate and the member will be responsible for the shortfall, as a co-payment.
2. 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 specific 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. 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.
3. 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:
- Addison’s disease
- Asthma
- Bipolar mood disorder
- Bronchiectasis
- Cardiac failure
- Cardiomyopathy
- Chronic renal disease
- COPD – chronic obstructive pulmonary disease
- Coronary artery disease
- Crohn's disease
- Diabetes insipidus
- Diabetes mellitus type 1
- Diabetes mellitus type 2
- Dysrhythmias
- Epilepsy
- Glaucoma
- Haemophilia
- Hyperlipidaemia (high cholesterol)
- Hypertension
- Hypothyroidism
- Multiple sclerosis
- Parkinson's disease
- Rheumatoid arthritis
- Schizophrenia
- Systemic lupus erythematosus
- Ulcerative colitis
- HIV and AIDS
Cover for medicines for the treatment of the Chronic Disease List conditions
Discovery Health will cover medicines in full without co-payments or limits if
- members use medicines that are listed on the medicine list, and
- claims are submitted electronically through MediKredit or through a dispensing provider.
- For 2012, KeyCare members can use their chosen primary dispensing GP, Optipharm, DisChem or Clicks pharmacies. .
- Delta Saver and Core Plans can use any DisChem, Clicks and Direct medicines pharmacies
Understanding what the medicine list is
The medicine list (also called a formulary) is a list of medicines we cover in full for the treatment of the listed 27 Chronic Disease List conditions. It is based on treatment algorithms developed by the Council for Medical Schemes. These treatment algorithms specify the class of medicines needed to treat conditions. Our pharmacists and doctors have also used clinical and actuarial information to design a medicine list that contains medicines that are clinically appropriate and cost-effective.
Discovery Health will cover medicines up to a rand limit for medicines not on the medicine list
If members use medicines that are either a combination of some medicines on the list and some off the list, or use none of the medicines on the list; we will pay the medicine claim up to a monthly Chronic Drug Amount.
Where the cost of a member’s medicines is more than the Chronic Drug Amount, the member will be responsible to pay the difference (co-payment). We will not fund the co-payment from the member’s day-to-day benefits as the Medical Schemes Act does not allow us to cover the difference from members’ day-to-day benefits.
If a member doesn’t use the full Chronic Drug Amount, we will not carry it over to the next month.
Healthcare professionals can ask the Discovery Health Medical Scheme to review cover for medicines that are not included in the approved medicine list (formulary) for Prescribed Minimum Benefit conditions, by completing the Chronic medicine appeal form.
Cover for consultations and diagnostic tests
The Discovery Health Medical Scheme will pay the cost of certain consultations and diagnostic tests associated with the 27 conditions on the Chronic Disease List, based on positive clinical guidelines and registration on to the Chronic Illness Benefit programme.
The number of tests and consultations we cover are limited
Discovery Health carefully manages the Chronic Illness Benefit to ensure our members have cover for good quality, appropriate healthcare that is cost-effective, affordable and sustainable. We use strict clinical guidelines and expert advice to make sure we are funding the most appropriate healthcare.
The average number of diagnostic tests and consultations that we pay are determined based on clinical best practice and evidence. Only claims listed in the Prescribed Minimum Benefits treatment guidelines will be paid from the Chronic Illness Benefit, according to our Designated Service Provider rules.
How to claim from the Prescribed Minimum Benefits for tests and consultations for the Chronic Disease List conditions
If we have approved cover for the condition from the Chronic Illness Benefit, members must send the accounts for any test or consultation that forms part of the treatment for the condition to us as normal. The accounts must show the ICD-10 code and be within the scheme’s basket of care for that condition.
Accounts that do not have the valid ICD-10 codes will be paid from available money in the member’s day-to-day benefits (Medical Savings Account and Above Threshold Benefit) subject to the plan type and the availability of funds and benefits, as we are unable to identify the claims as a Prescribed Minimum Benefit claim.
How to apply for cover for any one or more of the Chronic Disease List conditions
- Members need to send us a completed Chronic Illness Benefit application form CIB application form.
How to apply for cover for HIV and AIDS
- Members need to send us a completed HIVCare application form HIVCare Programme application form
Appeal process for Prescribed Minimum Benefits
We will only consider an appeal in certain circumstances. These include:
- medicines which are listed in the document 'Guidelines on non-substitutable medicines' issued by the Medicines Control Council
- clear and demonstrable clinical evidence of failed therapy or adverse drug reactions to medicine on the medicine list
- medicines that require clinical entry criteria, as defined in the algorithms, and
- additional consultations, pathology or radiology, depending on the severity of the member’s condition.
An appeal process does not guarantee a positive outcome and it also doesn’t change the cover of the Prescribed Minimum Benefits.
Once we’ve reviewed the case, we will contact the member with feedback. If we decline an appeal for certain medicines, members can still get the non-formulary medicines, which we will fund up to the Chronic Drug Amount. If there is a co-payment, the member will be responsible to pay this difference to the pharmacy.
Chronic medicine appeal form
Application for out-of-hospital management of a Prescribed Minimum Benefit condition
Oncology PMB application form
Request for extra Prescribed Minimum Benefit (PMB) cover for HIV
Application for additional out-of-hospital treatment over and above that provided by the Prescribed Minimum Benefits
Paying approved Prescribed Minimum Benefit claims
Discovery Health will cover the diagnosis, treatment and costs of Prescribed Minimum Benefits in full without co-payments or limits if all services are received from the Designated Service Providers.
If a member voluntarily chooses to receive services from a non-designated service provider, we will pay the facility and the related accounts at 80% of the Discovery Health Rate and the member will be responsible for the shortfall, as a co-payment.
Understanding what an involuntary service is
The term involuntary service applies in three scenarios:
- When the service was not available from the designated service provider or would not be provided without unreasonable delay;
- When immediate medical or surgical treatment for a 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
- There was no designated service provider within reasonable proximity to the beneficiary's ordinary place of business or personal residence, and is within a 50km radius.
The ICD-10 code on the claim provides us with information to identify treatments that should be paid as a Prescribed Minimum Benefit, as per the authorisation granted.
It is therefore essential that all accounts are submitted with valid ICD-10 codes for the condition authorised. This allows us to pay the accounts correctly from the Prescribed Minimum Benefits.
