Interpretation and Application of the Prescribed Minimum Benefits

Prescribed Minimum Benefits (PMBs) were first introduced when the Medical Schemes Act of 1998 (MSA) was promulgated. This Act saw the transformation of schemes from ‘insurance’ organisations to entities that entrenched the principles of social solidarity.

The PMBs are a set of nearly three hundred defined benefits to which all medical scheme members have access, regardless of the option they have selected. The aim is to provide financial protection to members and to improve their health and well-being.

The issues around payment and treatment relating to PMBs remain vexing and are the source of most complaints received by the Council for Medical Schemes.

Regulation 8 of the MSA stipulates that medical schemes must pay in full for the diagnosis, treatment and care costs of the PMB conditions. In the absence of a regulated tariff for healthcare providers, the ‘cost’ of a PMB is variable – thereby making accurate budgeting difficult for schemes.

To assist the industry in their understanding of the PMBs in the present and the proposed changes, 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 the interpretation and application of 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 Prescribed Minimum Benefits?
  • Underwriting in the context of PMBs
  • Exclusions – do they apply to PMBs
  • Understanding ‘Diagnosis and Treatment Pairs’ (DTPs)
  • Entitlement to benefits for the DTPs.
  • Identifying ‘Emergency conditions’
  • Examining the ‘Chronic Disease List’ (CDL)
  • The implications of PMBs for medical schemes
  • The payment of PMBs

Risk Management for the PMB Benefits

  • Managed care programmes
  • Standards for managed care
  • Designated Service Provider Networks
  • The PMB Code of Conduct 2017
  • 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
  • Case studies

CPD Points

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

Training dates

Johannesburg

18 and 19 July 2019

Cost R4 500 per attendee VAT exclusive

Venue

Apollo Hotel, 158 Bram Fischer Drive, Ferndale, Randburg Johannesburg Phone: 011 787 5434 GPS Coordinates: 26,09848°S / 28,00377°E

 Cape Town

30 and 31 July 2019

Venue

Pepper Club, Corner Loop and Pepper Street, Cape Town (Tel number: 021 812 8899)

Cost R4 800 per attendee VAT exclusive

Registration

 Johannesburg - Click here to   Download    the registration form.

  Cape Town - Click here to   Download    the registration form.

Training Date: 7/18/2019

Date: 4/3/2019