The Council for Medical Schemes (CMS) introduced Prescribed Minimum Benefits (PMBs) into the Medical Schemes Act to ensure that members of medical schemes would not run out of benefits for certain conditions and cause them to pay for medical treatment and services out of pocket. These PMBs cover a wide range of chronic conditions, such as meningitis, various cancers, menopausal management, cardiac treatment and many others including medical emergencies.
Everything you need to know about PMBs:
Every medical scheme in the country, including Wooltru Healthcare Fund (the Fund), is required to provide cover to its members for medical services related to the management of a specified number of PMB health conditions defined in the Medical Schemes Act.
The cover includes costs relating to the diagnosis and treatment of:
done The 26 common chronic health conditions on the Chronic Disease List (CDL) - see listed below.
done 270 other listed health conditions known as the Diagnosis and Treatment Pairs (DTPs). Please click here to view the 270 DTPs.
done An emergency medical condition that results in hospitalisation. Should you go to an emergency centre and the doctor does not admit you to hospital, the costs of the treatment will be paid as follows: Network Option - Emergency visit benefit; Saver and Comprehensive options - from Medical Savings Account (MSA).
Where the diagnosis and treatment was obtained from a Designated Service Provider (DSP), the Fund will cover the cost thereof in full, without you having to make a co-payment.
What is an ICD-10 code?
This is a diagnosis code that all healthcare service providers have to include on accounts that are submitted to the Fund for payment. This code ensures that the treatment you received from the service provider is paid from the correct benefit plan. Should this code not appear on the accounts, the Fund will not be able to process them for payment.
These information sheets are for your information only and is not a substitute for medical advice. The specifics of your condition and treatment should be discussed with your treating doctor to establish the optimal treatment plan for you as an individual.
Click here to read more about these chronic conditions.
|The Chronic Disease List (CDL) / 26 Prescribed Minimum Benefit (PMB) conditions|
|Addison's disease||Crohn's disease||Hypertension (high blood pressure)|
|Bipolar mood disorder||Diabetes mellitus types 1 & 2||Multiple sclerosis|
|Bronchiectasis||Dysrhythmia (irregular heartbeats)||Parkinson's disease|
|Cardiac failure||Epilepsy||Rheumatoid arthritis|
(disease of the heart muscle)
|Chronic renal disease||Haemophilia||Systemic lupus erythematosus|
|Coronary artery disease||HIV/AIDS||Ulcerative colitis
|Chronic obstructive pulmonary disorder||Hypertension (high blood pressure)|