Prescribed Minimum Benefits
This programme is designed to assist medical schemes in managing the costs related to chronic conditions contained in the Chronic Disease List (CDL) and other conditions within the ±270 Diagnosis Treatment Pairs (DTPs) of the Prescribed Minimum Benefits (PMBs) Regulations and which are not otherwise managed in our Disease Management Programmes. The programme takes a holistic view of the member's condition and provides a comprehensive Care Plan authorising medication, consultations and investigations. These Care Plans are in line with the treatment algorithms published by the Council of Medical Schemes. Where treatment is inadequate, baseline unstable Care Plans are used to adjust the patient-specific Care Plan.
In compliance with Risk Equalisation Fund (REF) requirements, members diagnosed with PMB CDL condition(s) and other chronic conditions within the 270 DTPs must submit an application form to access funding from the chronic medication benefit. Hospital admissions for DTP conditions are managed through the Hospital Risk Management Programme.
On authorisation, all costs relating to these PMB conditions are paid from a dedicated PMB benefit. Care Plans are automatically generated based on ‘trigger' claims received and each Care Plan may be further customised based on the individual's needs. Care Plans for more than one condition in a patient are automatically integrated into a single Care Plan.
A panel of specialists and clinicians has carefully developed each Care Plan to ensure that members will receive the appropriate level of care in a cost-effective way. In certain circumstances, an appeal will be considered, for example, when additional consultations, pathology or radiology are required depending on the severity of the member's condition.
Background
The Prescribed Minimum Benefits legislation which took effect 1 January 2004 requires all medical schemes to pay in full for the medical care, pathology, radiology and medication for the treatment of 25 listed chronic conditions. To avoid exhaustion of members' benefits for these chronic conditions, medical schemes are required to fund the treatment from insured benefits i.e. PMB benefits may not be paid for from medical savings accounts. Legislation does, however, permit medical schemes to use managed care tools to ensure that the treatment received for these conditions are both appropriate and cost-effective.