PMB Overview

The current debate on PMBs and Regulation 8

Medical aid members are guaranteed certain minimum benefits by the Medical Schemes Act no. 131 of 1998 in the form of Prescribed Minimum Benefits (PMBs). The guidelines according to which these minimum benefits are granted to members are set out in Regulation 8 of this Act.

While this Regulation clearly outlines which illnesses are covered and their applicable treatment protocols, its provisions for how medical aid schemes should pay for costs associated with these illnesses is not defined explicitly.

Current legislation prescribes that medical schemes must pay costs for PMB conditions in full, as set out in Regulation 8 (1) of the Act. This Regulation states that "any benefit option offered by a medical scheme must pay in full, without co-payment or the use of deductibles, the diagnosis, treatment and care costs of the Prescribed Minimum Benefits".

The intention was to make sure that all medical scheme members are guaranteed access to healthcare cover when they need it.

However, the provision for payment in full is proving to be a dilemma for many medical schemes even going so far as to threaten their sustainability owing to the fact that the Act does not define payment tariffs for PMBs.

During 2004, the Competition Commission ruled that determined tariffs were uncompetitive. This has led service providers to interpret this Regulation as a blank cheque and, in some instances, to charge exorbitant rates for PMB treatment.

Schemes pay for claims from a limited pool of funds made up of member contributions. Unpredictable charges for PMB treatment mean that medical schemes have to consider huge contribution increases or limits to certain benefits in order to make provision for the potential high financial risk PMB claims pose.

The Department of Health is mandated by the constitution to provide all South Africans with access to healthcare and; through the Council for Medical Schemes (CMS), ensures that medical scheme members are protected by the Act.

The true intention of Regulation 8 is evident when it is viewed in its entirety, not by selectively focusing on certain of its sections.

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