Medical Aid – Minimum Benefits or Maximum Costs?

Prescribed Minimum Benefits (PMB’s) constitute by and large the most significant part of medical schemes’ overall healthcare expenditure. With medical scheme legislation dictating that these benefits must be paid in full under certain conditions, the relevance of the “Minimum” becomes questionable and even ironic, when viewed against the unlimited costs it represents. The intention behind establishing a set of basic benefits to be available to all members of all medical schemes, regardless of option or contribution, is amenable.

Through the PMB’s a member gains access to chronic medication for treatment of 26 different chronic conditions and in addition, hospital-based care for more than 270 diagnosed treatment scenario’s, including any medical emergency. However, medical schemes have to fund these benefits in full, without co-payment or any limits being imposed. Medical schemes are not afforded any additional funds from which to pay these benefits, ie PMB’s are funded from the same member contributions as all other benefits. Schemes may insist on the use of a designated service provider before allowing these unlimited benefits, however, even this safe-guard is subject to terms and conditions and completely void in the case of any emergency.

With the requirement that PMB’s must be paid in full, an expectation is created amongst the public that medical schemes should be able to provide the necessary funding, without question. Through this expectation an opportunity for abuse and exploitation is unfortunately also created.

Selfmed Medical Scheme’s spokesperson explains: “PMB’s are being exploited by service providers who are fully au fait with the Regulations. Certainly not all providers are at fault. However, some providers have been found to charge up to 4 times more than the accepted medical scheme (NHRPL) rates if a service falls within the ambit of the PMB’s, knowing that their services must be reimbursed at cost.”

“Members, relying on what they read in the media, will not waiver to complain about a scheme not funding his/her PMB account in full. But, how many members will stand up for their scheme by going back to the service provider and question the undue behaviour and excessive fees being charged?”

The healthcare industry, in promoting PMB’s, disregards the fact that medical schemes can only fund benefits within the boundaries set by its total contribution income.

A scheme can only fund benefits in accordance with the contribution income it receives per option.

By allowing unlimited benefits for PMB’s , schemes face the risk of paying out more in terms of benefits compared to what it receives in contributions.

As a result, higher contribution increases become necessary to compensate for the increased expenditure.

By affording practitioners carte blanche, medical schemes may soon end up heading towards a scenario of not being able to pay, as opposed to not wanting or avoiding to pay.

“It is because we care that we alert our members to the impact of PMB’s and the current exploitation thereof. At Selfmed we pride ourselves on providing members sincerity and security as part of our value statement. By putting our members’ interests first, we need to ensure that they understand the impact that such open-ended benefit may have on their future contribution increases and the Scheme’s sustainability.”

To ensure a sustainable healthcare industry, all stake holders need to work together and not against each other. Members are in the unique position that they can actively negotiate (and not only accept) the fees that their practitioners charge, thereby sharing in the responsibility towards acquiring a better healthcare outcome for all.