Medical Scheme premiums increased by CPI + 5% in January for most medical schemes. These increases are a result of an ageing, sicker population using more services, and not by medical schemes affording doctors excessive tariff increases. As a medical scheme member, being aware of your rights as far as Prescribed Minimum Benefits (PMBs) go, could save you a lot of out-of-pocket healthcare expenses in the coming year.
“Lack of knowledge of PMBs ends up costing scheme members unnecessarily out of pocket for essential medical attention. And worse still, some members find themselves exhausting their savings on treatment or care that should have been accessed as PMBs.
These PMBs may not be paid from savings, according to the Medical Schemes Act” says Dr Johann Serfontein, CEO of the Ophthalmology Management Group (OMG), which manages private practice issues on behalf of the Ophthalmological Society of South Africa (OSSA).
PMBs, as defined by law, are the minimum level of diagnosis, treatment and care costs your medical scheme must cover in full. Many of us have probably found ourselves in situations where, although we have medical aid, paying what healthcare professionals call a co-payment. This is because medical scheme tariff increase for doctors since 2006 have historically not reflected increases in the costs of running practices and also because schemes have designated service provider networks (DSPs). These DSPs are doctors and hospitals that your medical scheme chooses as their preferred provider when you need treatment or care. In situations where you opt for a non-DSP, you often have to pay a portion of the bill, which is the co-payment.
“One of the big concerns in eye care is that DSP networks often do not consider the number of sub specialist fields in ophthalmology. An ophthalmologist with a special interest in glaucoma is not necessarily the right person to see for a complex Retinal detachment, for instance. Scheme DSPs do not differentiate between such sub-specialities. Sometimes schemes appoint facilities as DSPs, who do not have the required equipment for ophthalmic surgery. Patients then face an uphill battle to get co-payments waived. It is important to remember that emergencies such as Retinal detachments, which require same-day surgery, are almost always PMBs”