Interpretation and Application of the Prescribed Minimum Benefits

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.

IHRM has developed a two-day PMB programme designed to provide call centre agents, case managers, fund managers, claims assessors, medical scheme trustees and principal officers with a working knowledge of medical scheme benefit design, managed care, and the interpretation and application of the PMBs. This programme includes both theory and practical case studies.

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

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
  • Rights and responsibilities of medical schemes, members and providers
  • Proposed changes to the basket of PMBs including the recommendations by the Health Market Inquiry

Programme options

Option one – register for the two-day facilitation programme and complete an online assessment. On successful completion of the online assessment you receive a certificate of attendance.

Option two – INSETA accredited skills programme (16 credits) - register for the two-day facilitation programme and complete an assignment. The assignment will take you about three weeks to complete. We will assess the assignment and when you are competent you will write a three-hour exam.

Option two does have BEE benefits for employers.

Attendance to both facilitation days is compulsory

Cost

Option one - R4 500 excluding VAT

Option two - R6 000 excluding VAT

Training dates

2 to 3 April 2020 -  Download the registration form and once complete email it to training@ihrm.co.za

16 to 17 July 2020 -  Download the registration form and once complete email it to training@ihrm.co.za

Venue

Glenhove Conference and Training Centre, Melrose Estate, Johannesburg

For in-house training contact Zandile Thabethe on training@ihrm.co.za

CPD Points

The FPI has allocated 11 CPD points in total for this programme for attendance and successful completion of an assessment

Training Date: 7/18/2019

Date: 4/3/2019