MHM Magazine

Prescribed Minimum Benefits (PMBs) are a set of defined benefits to ensure that all medical scheme members have access to certain minimum health services, regardless of the benefit 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. PMBs are a feature of the Medical Schemes Act, in terms of which medical schemes have to cover the costs related to the diagnosis, treatment and care of: • Any emergency medical condition; • A limited set of 271 medical conditions (defined in the Diagnosis Treatment Pairs); and • 26 chronic conditions (defined in the Chronic Disease List – of which Bipolar Disorder and Schizophrenia are included). When deciding whether a condition is a PMB, the doctor should only look at the symptoms and not at any other factors, such as how the injury or condition was contracted. This approach is called diagnosis- based. Once the diagnosis has been made, the appropriate treatment and care is decided upon as well as where the patient should receive the treatment (at a hospital, as an outpatient or at a doctor’s rooms). Why do we have PMBs? There are two main reasons why PMBs were created: • To ensure medical scheme beneficiaries have continuous healthcare. This means that even if a member’s benefits for a year have run out, the medical scheme has to pay for the treatment of PMB conditions; and • To ensure that healthcare is paid for by the correct parties. Medical scheme members with PMB conditions are entitled to the specified treatments and these have to be covered by their medical scheme, even if the patients were treated at a state hospital. But there are other valid reasons too: • To provide minimum healthcare to everybody who needs it, regardless of their age, state of health or the medical scheme cover option they belong to; • PMBs have a part to play in ensuring that medical schemes remain financially healthy. When beneficiaries receive good care on an ongoing basis, their general wellness improves, resulting in fewer serious conditions that are expensive to treat; • And to ensure that healthcare is paid for by the correct parties. Medical scheme members with PMB conditions are entitled to the specified treatments and these have to be covered by their medical scheme, even if the patients were treated at a state hospital. To download the full list of PMB conditions and ICD10 codes, go to https://www. medicalschemes.co.za/ resources/pmb/pmb- conditions/ References available on request. WHAT ARE PRESCRIBED MINIMUM BENEFITS? PMBs for Mental Health Code Diagnosis Treatment 182T Abuse or dependence on psychoactive substance, including alcohol Hospital-based management up to 3 weeks / year 910T Acute delusional mood, anxiety, personality, perception disorders and organic mental disorder caused by drugs Hospital-based management up to 3 days 901T Acute stress disorder accompanied by recent significant trauma, including physical or sexual abuse Hospital admission for psychotherapy / counselling up to 3 days, or up to 12 outpatient psychotherapy / counselling contacts 910T Alcohol withdrawal delirium; alcohol intoxication delirium Hospital-based management up to 3 days leading to rehabilitation 908T Anorexia Nervosa and Bulimia Nervosa Hospital-based management up to 3 weeks / year or minimum of 15 outpatient contacts per year 903T Attempted suicide, irrespective of cause Hospital-based management up to 3 days or up to 6 outpatient contacts 184T Brief reactive psychosis Hospital-based management up to 3 weeks / year| 910T Delirium: Amphetamine, Cocaine, or other psychoactive substance Hospital-based management up to 3 days 902T Major affective disorders, including unipolar and bipolar depression Hospital-based management up to 3 weeks / year including inpatient electroconvulsive therapy and inpatient psychotherapy) or outpatient psychotherapy of up to 15 contacts 907T Schizophrenic and paranoid delusional disorders Hospital-based management up to 3 weeks / year 909T Treatable dementia Admission for initial diagnosis; management of acute psychotic symptoms - up to 1 week MHM | 2024 | Volume 11 | Issue 4 | What are Prescribed Minimum Benefits? MHM 30 | MENTAL HEALTH MATTERS | 2024 | Issue 4 H