A Start -10 Draft Cancer Prescribed Minimum Benefits (PMBs) + plus 1 added

PMBs are a vital tool used by medical schemes because they explain the minimum services for which your medical scheme will pay. These are the “benefits” of belonging to a private medical scheme. As beneficiaries, we must know about these rather than the number of free movies!

The PMBs have been a bone of contention for over a decade because they are outdated and don’t reflect current practice and care. Usually to the user’s detriment. The custodian of PMBs is the Council for Medical Schemes (CMS). Remember, PMBs are just as important for public sector care as this is the process that will be used to start the NHI care benefits.

NCDs categories at last

A recently published draft PMB benefit classification refocuses on health services. The change, from long-criticised disease /condition related benefit packages to one based on services, is welcomed. Look at the draft, it and give your comments. These are your health care benefits which serve as a minimum package that must be available in different settings from a primary care setting to hospitals.

More work is needed to further expand the categories to include the setting in which the service must be accessed:

The classification includes NCDs and communicable diseases in one category. This is probably meant to reflect that the chronic and comorbid nature of the conditions: The SA NCDA hopes it heralds integrated health care. These are the elements of NCDs care:

  • Screening and assessment of risk factors and co-morbidities
  • Initiation of early treatment
  • Screening and management of complications
  • Follow up and monitoring of treatment adherence
  • Interpretation of common laboratory and radiological results
  • Specialised geriatric care, including foot care
  • Referral to a higher level of care when required.

PMB cancer definition starts

The  PMB Benefit Definition Project (started in 2010) must clarify the benefits to which medical scheme users are entitled in terms of the Medical Schemes Act (131 of 1998). Sadly, these guidelines lack a legal status.

The project is a CMS-led process that uses criteria to define the prevention and treatment for a specific condition. There are lots and lots of conditions to get through. Cervical cancer, a major problem, has yet to be published.
A CMS-appointed Clinical Advisory Committee (one per medical discipline) with members drawn from medical and health professions, funders (medical schemes) and patient groups. However, the mechanism of patient group involvement is neither clear nor transparent. Patient groups need to be vigilant on this matter as the CMS does not have a clean record of including patients or “users” in a meaningful way.

Eleven  PMB draft definitions released in the last year all relate to cancer. Medical scheme users should comment to make it relevant. There is no time limit for comments stated in the drafts but another newsletter version shows it to be about 3 weeks from release date. However, you are encouraged to comment no matter the timeline as these are your benefits and make sure that they meet your needs.

Draft PMB definition guideline title with links Date released
1.     Non-small cell lung cancer 26 Feb 2018
2.     Medical nutrition therapy in palliative care (adults) 12 Feb 2018
3.     Small cell lung cancer 1 Feb 2018
4.     Mesothelioma 25 Jan 2018
5.     Hepatocellular carcinoma 6 Dec 2017
6.     Early stage colon and rectal cancer 2nd edition 4 Sept 2017
7.     Metastatic colon and rectal cancer 2nd edition 4 Sept 2017
8.     Early stage pancreatic cancer 2nd Edition 31 Mar 2017
9.     Early stage oesophageal cancer 2nd edition 31 Mar 2017
10.  Best supportive care for 4 cancers 2nd edition 31 Mar 2017
11.  Early stage gastric/ gastro-oesophageal junction cancer 2nd edition 31 Mar 2017

CMS Script on oesophageal cancer

Council for Medical Aid Schemes – Undesired Business Practice Submissions

The Council for Medical Aids Schemes has stated in their latest circular that submissions to the recent Undesired Business Practice. A proforma document has been circulated that is not aligned with the method of submission required.

This proforma document has been circulated through pharmacies and brokers to the public. The CMS states that this is not the correct procedure for applications. This is taken seriously by the council as it undermines what the Medical Aid Schemes Act seeks to achieve. The incorrect procedure will invalidate submissions and thus counter the aims of the Undesired Business Practices document. This was noted and publicised in Government Gazette 435 of 2017

The persons wishing to submit applications only need indicate whether co-payments are levied when they use service providers for medication not listed by the medical aid scheme, sign their name and provide personal details.

There are provisions for members of the council to reduce their costs when funding the Prescribed Minimum Benefits (PMBs). Furthermore, there are allowances for instances where the listed service providers are too far from the person’s place of work or home.


Breast cancer – know your medical scheme benefits

Credits: The Council for Medical Schemes Script Newsletter Issue 13 2014

Breast cancer is the most common cancer in women in rich and poor countries. In 2012, breast cancer was present in 6.3 million women worldwide. According to the World Health Organization, breast cancer is the most common cause of cancer death among women with over 522 000 deaths recorded in 2012. According to the National Cancer Registry, 1 in 27 South African women will be diagnosed with breast cancer in her lifetime. Men can get breast cancer but it is rarely diagnosed. Conditions related to breast cancer are prescribed minimum benefit (PMB) conditions. To read more, please click here.

If you are a member of a medical scheme you need to understand the concept of PMBs. For more information click here.

In memory of Yvonne October 2014