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| Which conditions are covered? |
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The Regulations to the Medical Schemes Act in
Annexure A provide a long list of conditions identified as Prescribed
Minimum Benefits. The list is in the form of Diagnosis
and Treatment Pairs (DTPs).
A DTP links a specific diagnosis to a treatment and therefore
broadly indicates how each of the approximately 270 PMB conditions
should be treated. The treatment and care of PMB conditions should
be based on healthcare that has proven to work best, taking affordability
into consideration. Should there be a disagreement about the
treatment of a specific case, the standards (also called practice
and protocols) in force in the public sector will be applied.
The treatment and care of some of the conditions included in the
DTP may include chronic medicine, e.g. HIV-infection and menopausal
management. In these cases, the public sector protocols will also
apply to the chronic medication. |
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| Here is an example of a DTP as it appears in the Medical
Schemes Act: |
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| Code |
Diagnosis |
Treatment |
| 109A |
Vertebral dislocations/fractures,
open or closed with injury to spinal cord |
Repair/reconstruction; medical
management; inpatient rehabilitation up to two months |
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| The 270 conditions that qualify for PMB cover
are diagnosis-specific and include a range of ailments that can
be divided into 15 broad categories: |
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| PMB Category |
Example |
| Brain and nervous system |
Stroke |
| Eye |
Glaucoma |
| Ear, nose, mouth and throat |
Cancer of oral cavity, pharynx,
nose, ear, and larynx |
| Respiratory system |
Pneumonia |
| Heart and vasculature (blood
vessels) |
Heart attacks |
| Gastro-intestinal system |
Appendicitis |
| Liver, pancreas and spleen |
Gallstones with cholecystitis |
| Musculoskeletal system (muscles
and bones); Trauma NOS |
Fracture of the hip |
| Skin and breast |
Treatable breast cancer |
| Endocrine, metabolic and nutritional |
Disorders of the parathyroid
gland |
| Urinary and male genital system |
End-stage kidney disease |
| Female reproductive system |
Cancer of the cervix, ovaries
and uterus |
| Pregnancy and childbirth |
Antenatal and obstetric care
requiring hospitalisation, including delivery |
Haematological, infectious and
miscellaneous systemic conditions |
HIV/Aids and TB |
| Mental illness |
Shizophrenia |
| Chronic conditions |
Asthma, diabetes, epilepsy,
hypothyroidism, schizophrenia, glaucoma, hypertension |
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| No exclusions |
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| Medical schemes often have a list of conditions – such
as cosmetic surgery – for which they will not pay, or circumstances – such
as travel costs and examinations for insurance purposes – under
which a member has no cover. These are called exclusions. Exclusions,
however, do not apply to PMBs. If you contract septicaemia after
cosmetic surgery, for example, your scheme has to provide healthcare
cover for the septicaemia part because septicaemia is a PMB.
(Cosmetic surgery remains an exclusion.) PMBs are concerned about
the diagnosis; it doesn’t matter how you got the condition. |
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