PMB’s – Educate Yourself
If you are in South Africa, you need to become best friends with the Prescribed Minimum Benefits available on your medical aid. I have learnt so much over the last 6 months and am currently in a bit of a war with my medical aid.
What is a Prescribed Minimum Benefit?
Prescribed Minimum Benefits (PMBs) are a set of minimum health services that all registered medical schemes in South Africa must provide to their members. PMBs apply regardless of the plan type a member has. Source
What PMBs cover
- Emergency medical conditions: Any sudden or unexpected health condition that requires immediate medical treatment
- A list of 271 medical conditions: Defined in the Diagnosis Treatment Pairs (DTPs)
- A list of 26 chronic conditions: Defined in the Chronic Disease List (CDL)
Purpose of PMBs
PMBs ensure that all medical scheme members have access to continuous care for a defined list of conditions. This aims to improve health and well-being and to make healthcare more affordable.
How to access PMBs
To benefit from PMBs, you must meet certain requirements, including:
- The condition must qualify for cover and be on the list of defined PMB conditions
- The treatment needed must match the treatments in the defined benefits on the PMB list
You can find the list of 271 PMB medical conditions on the Council for Medical Schemes website. Save this list and check it when and if you need something health related.
My Story with PMB’s
I had heard about these but hadn’t really paid much attention if I am honest. We haven’t really needed much in terms of medical care so it wasn’t really much of an issue.
When Cameron died, Eve told me that we can all get therapy as a PMB. I called our medical aid, they said nope, not true. *sigh* I was deep in my grief at the time so didn’t push but Eve was adamant we had to try. David spoke to his therapist who was so helpful and found us each a therapist who would claim our therapy as a PMB.
It all boils down to the code they use.
Acute stress disorder accompanied by recent significant trauma is a PMB. The death of a child, sibling IS a traumatic event. Our therapists captured it as such and submitted motivations which allowed us to all receive the counselling we needed as a PMB.
There is a whole section devoted to Mental Health and it includes both therapy and in hospital treatment. Which is why I was able to go to the clinic.
If you or a loved one are struggling with mental health, chat to your health care provider about these. You might be able to get the help you (or your loved one) needs. I have a lot of guilt about not finding out more about this for Cameron when he was struggling at the end of his 3rd year.
During my deep dive into PMB’s, I discovered that Menopause is a PMB as well.
“Menopausal management, anomalies of ovaries, primary and secondary amenorrhoea, female sex hormones abnormalities NOS, including hirsutism Medical and surgical management, including hormone replacement therapy.
The challenge with this one is that menopausal management is a pretty vague term but it again, comes down to the motivation your Dr sends to the medical aid.
My medical aid aren’t particularly helpful when it comes to PMB’s – they just tell me “no its not covered”. If you get the same response, keep fighting. Speak to your Dr, get them to send in the motivations needed. And if they still refuse, you can lodge a complaint with co********@me************.com.
PMB’s were put in place for a reason and are available to everyone who has a medical aid, regardless of the plan you are on. It is your right to have access to these, even if your medical aid’s nose is out of joint.
