These cover the basic level of cover for a defined set of conditions. All medical schemes are required by law to cover 270 hospital based conditions and 25 chronic conditions in full without co-payment or deductibles, as well as any emergency treatment and certain out of hospital treatment. This means that all schemes must provide PMB level of care at cost for these conditions.
It is important to note that qualification as a PMB is not based solely on the diagnosis (condition) but also on the treatment provided (level of care). This means that although your employee’s condition may be a PMB condition, the scheme would only be obliged to fund it in full if the treatment provided was deemed to be PMB level of care.
The Medical Schemes Act 131 of 1998 allows schemes to require members to make use of Designated Service Providers (DSPs) in order for a member to be entitled to funding in full. Schemes may also apply formularies – a list of medicines that should be used to treat PMBs, and managed care protocols – based on evidence-based medicine and cost-effectiveness principles to manage this benefit.