Disrupting Prescribed Minimum Benefits

In December 2019 the CMS published Circular 80 informing the medical scheme and insurance industry that no Low Cost Benefit Option products will be allowed beyond 2021. This is in sharp contrast to Circular 18 of 2019 envisaging a low cost benefit package. Circular 82 published in December 2019 stated that no additional exemptions will be granted for the creation of products for the low income market segment.

IHRM has developed a two-day PMB programme for call centre agents, brokers, case managers, fund managers, claims assessors, medical scheme trustees and principal officers

The Prescribed Minimum Benefits (PMBs) are a set of nearly three hundred defined benefits to which all medical scheme members are entitled, regardless of the option they have selected. The PMBs were first introduced when the Medical Schemes Act of 1998 was promulgated. The issues around payment and treatment related to PMBs remain vexing and are the source of most complaints received by the Council for Medical Schemes. PMBs have not achieved what they were intended to do. The PMB basket is under review with a focus on primary healthcare. This programme looks at the current PMB basket, and the impact of the CMS Circulars and finding and recommendations of the Health Market Inquiry Report.

Programme

Introduction to medical scheme benefit design

  • Benefit design
  • Medical scheme expenditure
  • Rationale for the introduction of PMBs
  • What are the PMBs?
  • Underwriting in the context of PMBs
  • Exclusions – do they apply to PMBs?
  • The Diagnosis and Treatment Pairs (DTPs)
  • Entitlement to benefits for the DTPs.
  • Identifying ‘Emergency conditions’
  • Examining the Chronic Disease List
  • The implications of PMBs for medical schemes
  • The payment of PMBs
  • Proposed primary health care package
  • Products for low-income market segments
  • Health Market Inquiry – PMB findings and recommendations

Risk management for the PMBs

  • Managed care programmes
  • Standards for managed care
  • Designated Service Provider Networks
  • The PMB Code of Conduct 2017
  • The complaint resolution process to be followed by medical schemes, members and providers

Attendees will receive a course pack, a copy of the Medical schemes Act. On successful completion of the online assessment a certificate of attendance will be issued.

Contact us to schedule in-house training on training @ihrm.co.za

All our training is being facilitated via online Teams Meetings and supported by a eLearning platform

CPD Points

The FPI has allocated 15 CPD points in total for this programme for attendance and successful completion of an assessment

FPI Approval number: FPI20030099 01 March 2020 - 01 March 2021

Training Date: 7/16/2020

Date: 4/3/2019