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Patient Rights Information

from the Council For Medical Schemes

What are PMBs?

Prescribed Minimum Benefits (PMB) is 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:

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).

Download 10 things no one tells you about PMB's

More Information

Pulmonary Hypertension is classified as one of the

271 DTP’s constituting the PMB Package

(under section 29 (1) (o) of the Medical Schemes Act).

(PMBs) Prescribed Minimum Benefits; (DTP) Diagnosis Treatment Pair

PMB DTP Code CONDITION MANAGEMENT ICD 10 CODE
901E Hypertension – acute life-threatening complications and malignant hypertension; renal artery stenosis and other curable hypertension Medical and surgical management I27.0 Primary pulmonary hypertension

I27.2 Other secondary pulmonary hypertension

Medical schemes are to pay for the diagnosis, treatment and care costs of these PMB conditions.

  • Medical Schemes may employ clinical entry criteria, treatment protocols, designated service providers and formularies to manage PMBs.

More Information On

Reimbursement of Treatment for PH

Should you require further information or assistance regarding reimbursement of treatment for PH, the Council for Medical Schemes can be contacted on:

TEL 0861 123 267 / 012 431 0500

FAX 012 431 0560 / 012 430 7644

www.medicalschemes.com

The Council for Medical Schemes is a statutory body established in terms of the Medical Schemes Act to provide regulatory oversight to the medical schemes industry. As part of their mission, the Council serves to act in an administratively fair and transparent manner, to:

  • Inform the public of their rights and duties
  • Ensure that all entities conducting the business of a medical scheme comply with the Medical Schemes act
  • Ensure that complaints raised by members and the public are handled appropriately and speedily

The Complaints

Procedure

Who can complain to the Registrar’s Office?

Any beneficiary or any person who is aggrieved with the conduct of a medical scheme can submit a complaint.

It is however very important to note that a prospective complainant should always first seek to resolve complaints through the complaints mechanisms in place at the respective medical scheme before approaching the Council for assistance.

Complaints can be submitted by any reasonable means such as a letter, fax, e-mail or in person at our Offices from Mondays to Fridays during 08:00 – 17:00.

More Information

www.medicalschemes.com

The Council for Medical Schemes is a statutory body established in terms of the Medical Schemes Act to provide regulatory oversight to the medical schemes industry. As part of their mission, the Council serves to act in an administratively fair and transparent manner, to:

  • Inform the public of their rights and duties
  • Ensure that all entities conducting the business of a medical scheme comply with the Medical Schemes act
  • Ensure that complaints raised by members and the public are handled appropriately and speedily

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