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Making sense of Prescribed Minimum Benefits

Posted by GapCover Blogger on 3/4/2016
More and more medical scheme members realise the value of investing in additional health cover products to insure themselves against out-of-pocket medical expenses.

GapCover® clients are covered against medical shortfalls that could occur when doctors charge more than what the medical scheme tariff is during in-hospital procedures.
GapCover vs PMBs
"The reality of the current medical industry is that specialists can charge up to 700% of the medical scheme's tariff and these shortfall amounts would be for the member's own account," says Deon Jooste of GapCover®.

There is however often confusion with regards to claims and outstanding medical invoices that are misinterpreted as medical shortfalls, but it actually relate to Prescribed Minimum Benefits (PMBs), which would not necessarily be covered by your gap cover policy.

What are these 'PMBs'?

This is a feature of the Medical Schemes Act that enforces medical schemes to cover the costs related to the diagnosis, treatment and care of a list of Prescribed Minimum Benefits (PMBs).

These sets of defined benefits ensure that all medical scheme members have access to certain minimum health services, regardless of the benefit option they have selected. The aim is to provide people with continuous care to improve their health and well-being and to make healthcare more affordable.

Medical Aid PMB Requirements"Because the codes linked to treatments and procedures, as well as the PMB list of conditions itself are so complex and often not easy accessible to the public, it could be difficult for the medical scheme member to understand what can be claimed and from where," says Deon.

For example: Scheme exclusions not applicable to PMB. Medical schemes often have a list of conditions - such as cosmetic surgery - for which they will not pay, or circumstances - such as travel costs and examinations for insurance purposes - under which a member has no cover. These exclusions, however, do not apply to PMBs. But, if you get septicaemia after cosmetic surgery, for example, your scheme has to provide healthcare cover for the septicaemia part because it's one of the listed PMB conditions.

PMBs are directly linked to the diagnosis; it doesn't matter how you got the condition.

"A situation where your medical scheme might not be willing to pay the full claim would be if you did not use the Designated Services Provider (DSP) linked to their PMB policies," says Deon. "Shortfalls for not using as DSP could then be charged, something which you will not be able to claim from GapCover® or CoPay Cover."

GapCover clients are not expected to understand all these details, underwriting, different regulations and medical scheme rules. "To avoid any disappointment or unnecessary and unplanned expenses, always check with your medical scheme broker first before you go for the procedure," Deon advises. "If you don't have a broker, you can also get a pre-approval consultation with your gap cover service provider."

For more information about GapCover®, read more here or fill our the application form and get covered.

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