What is PMB? - Medshield

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What is PMB?

What is PMB?

Prescribed Minimum Benefit (PMB) is a set of defined benefits that ensures that all medical scheme members have access to certain minimum health services, regardless of the benefits 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. These costs are related to the diagnosis, treatment and care of the following three clusters.

Cluster 1

EMERGENCY Medical Condition

An emergency medical condition means the sudden and/or unexpected onset of a health condition that requires immediate medical or surgical treatment.

If no treatment is available the emergency may result in weakened bodily function, serious and lasting damage to organs, limbs or other body parts or even death.

Cluster 2

Diagnostic Treatment Pairs (DTP)

Defined in the DTP list on the Council for Medical Schemes website. The Regulations to the Medical Schemes Act provide a long list of conditions identified as PMB conditions

The list is in the form of Diagnosis and Treatment Pairs. A DTP links a specific diagnosis to a treatment and therefore broadly indicates how each of the 270 PMB conditions should be treated and covered.

Cluster 3

26 Chronic Conditions

The Chronic Disease List (CDL) specifies medication and treatment for these conditions.

To ensure appropriate standards of healthcare an algorithm published in the Government Gazette can be regarded as benchmarks, or minimum standards for treatment.

PMB’s were created to:

  • Ensure that medical scheme beneficiaries have continuous healthcare. This means that even if a member’s benefits have run out, the medical scheme has to pay for the treatment of PMB conditions.
  • Ensure that healthcare is paid for by the correct parties. Medshield members with PMB conditions are entitled to specified treatments which have to be covered by the Scheme. These specified PMB treatments include treatment and medicines, subject to the use of Medshield’s Designated Service Provider treatment protocols and formularies.