medical aid for diabetics

Need to know: what are PMBs?

Did you know that if you have diabetes and you’re a member of a medical aid, they have to – by law – give you certain benefits for free? Nicole McCreedy explains all you need to know about PMBs.

If you’re a Type 1 or a Type 2 diabetic and you belong to a medical aid, you have the right to certain health services, known as Prescribed Minimum Benefits (PMBs). There are about 300 medical conditions where PMBs apply, and 26 of those are chronic conditions like Type 1 and Type 2 diabetes.

Your health is important

PMBs were introduced to the Medical Schemes Act to protect members. It doesn’t matter how old you are, how healthy you are, or which medical aid option you are on (yes – even hospital plan counts!) Your medical aid has to provide minimum healthcare if you have a chronic condition – at no extra cost. You shouldn’t have to pay extra (over and above your monthly medical aid contribution) for certain medical services for diabetes. Because the government has made this law, it is also impossible for medical aids to charge you more or force you to lose your medical aid cover because you have a serious medical condition.

When you can (and can’t) use PMBs

What does this mean? A medical aid must pay in full, without any co-payment from you, for the diagnosis, treatment and care costs of the PMB condition (your diabetes). The medical aid cannot use your medical savings account or day-to-day benefit to pay for PMBs. Remember, though, that PMBs are subject to pre-authorisation (you have to register your PMB with the medical aid first), protocols (specific treatment and medication guidelines), and making use of designated service providers (hospitals, pharmacies and doctors that they have chosen). So you can’t expect your medical aid to cover the costs of your diabetes care unless you play by their rules, and you may not be able to get the same doctors and medicine as you had before.

Sometimes, members will not have cover for PMBs from their medical aid. This can happen if you join a medical aid for the first time (without switching from another medical aid) or if you join a new medical aid more than 90 days after leaving the previous one. If this is the case, there is a waiting period, during which you won’t have access to the PMBs for any pre-existing condition for 12 months.

Diabetes treatment and PMBs

The treatment of diabetes focuses on the control of blood sugar levels. Treatment involves all aspects of your lifestyle, especially nutrition and exercise, but most people with diabetes also use medicine (usually insulin) at some point. Treatment of other risk factors, like blood pressure and high cholesterol, is also very important.

Both Type 1 and Type 2 diabetes qualify as PMBs and must be treated according to PMB regulations for diagnosis, medical management and medication. You can ask your medical aid about the following treatments that should be covered:

  • Visits to your doctor (GP or specialist – if authorised).
  • Dietary and disease education.
  • Annual eye exam for retinopathy.
  • Annual comprehensive foot exam.
  • Blood tests every 3 to 6 months.
  • Disease identification card or disc.
  • Home blood sugar testing.

How to get your Prescribed Minimum Benefits:

Step 1: Register

Phone your medical aid and tell them you want pre-authorisation for diabetes PMBs. They will ask for a code that your doctor will be able to give you. It is very important that you have the right ICD-10 code – this gives the right information about your condition and helps the medical aid to know what benefits you are allowed. A PMB condition can only be identified by the correct ICD-10 codes. If you give the wrong ICD-10 code, your PMB services might be paid from the wrong benefit (like your medical savings account), or it might not be paid at all if your day-to-day or hospital benefit limits have run out.

Step 2: Your service will be pre-authorised

After you have registered your chronic condition for PMB, your benefits will be authorised and you can ask for your PMB schedule, which tells you exactly what you get for free.

 

The A to Z of PMBs

Chronic Diseases List (CDL)
A list of the 26 conditions (including diabetes) that qualify for PMBs.

Chronic Medicine
Medicine used for the long-term treatment (three months or longer) of a chronic condition. The chronic medicine must be used to prevent or treat a serious medical condition, to sustain life and to delay the progress of a disease. It must also be the accepted treatment according to treatment guidelines (protocols).

Co-payments
The difference between the cover provided by the medical aid and the cost of the medical service – payable directly to the service provider.

Designated Service Provider (DSP)
Doctors and other health care providers who have been chosen by the aid to “provide its members diagnosis, treatment and care” for PMB conditions.

Emergency Medical Condition
A medical condition that needs immediate medical or surgical treatment.

Formulary
An official list of the medication that can be prescribed for the treatment of the 26 conditions on the Chronic Diseases List (CDL).

ICD-10 Codes
An international clinical code that describes a disease diagnosis. If you want to qualify for PMBs, you must be sure your doctor puts the correct ICD-10 code on all your forms.

PMB Medicine
Medicine for the treatment of the 26 conditions on the Chronic Diseases List (CDL) qualifies for PMBs, as long as you provide all the necessary information. This can be anything from a diagnosis by a specialist to results of certain tests – your medical aid will tell you what you need.

Prescribed Minimum Benefits (PMBs)
The minimum benefits that must be provided to all medical aid members. These include diagnosis, treatment and care costs for a number of conditions, including diabetes.

Protocols (Treatment Guidelines)
There is a minimum standard treatment for each PMB condition. Medical aids use these guidelines to come up with protocols (treatment guidelines) and formularies (lists of approved medication) to manage PMBs.

This article was reviewed by:

  • Alain Peddle, Discovery Health
  • Herman van Zyl, Principal financial advisor, HVZ Financial Consultants
  • Rossouw van Zyl, Brokers, t/a Medinet, Authorised Financial Service Provider
  • Michael A.J. Brown, Accredited Diabetes Educator,
Centre for Diabetes and Endocrinology, Houghton

 

What’s the Best Medical Aid for Diabetics?

Lisa has a question I’m sure we’d all like the answer to… Please weigh in and let’s see what the diabetes community in South Africa has to say about this!

best medical aid

I have been a government patient at Groote Schuur while I have been studying and now that I am in freelance work I am looking into medical aid. There are so many and it is so confusing.

As you have a network of diabetics at your fingertips I am sure that there is banter as to which one is best for us. I went to meet with Discovery and although they are the most popular in healthcare they would only start covering my pre-existing condition after 12 months. I looked at Fedhealth and they will cover my diabetic meds after 3 months so already I prefer them!

As I freelance I can only afford around the R1200 mark. When they say PMB does that mean that all diabetic health checks would be included as well as my meds or if i went to a GP would I have to pay for that consultation?!

Also the doctor I was seeing said as I am a brittle diabetic I would be a good candidate for the insulin pump but government healthcare cannot supply that due to the cost. Would any medical aid supply me with this….Lots of questions I hope you can help!

– Lisa Rouhana

Answer from our Editor, Bridget McNulty:

Hi Lisa!
I can definitely give you my perspective but would also be happy to put it on the Sweet Life community blog (www.sweetlifemag.co.za/ community) if you want input from other diabetics? I think more advice is always good!

PMBs are prescribed minimum benefits, and as a diabetic that includes all your meds, as long as you choose the ones that the medical aid has on their formulary (you can ask them for their formulary list to be sure yours are on there, but it’s generally possible to get any brand). They often won’t cover you for 3/12 months for any other check-ups, but they have to cover your chronic medicine. Ask to see the chronic illness benefit details and that will give you more clarity as to what you can get.

I’m on Discovery and I get all my meds and 4 x endocrinologist visits a year (they sometimes have to be reminded of this!) as part of the chronic benefit. I think most medical aids are pretty similar on hospital plan, but it’s definitely worth shopping around. I have a very nice Discovery broker if you want to chat to him? That’s generally how they work (and it’s no extra cost to you).

As for the pump, I know that it’s only the top tier medical aid that it gets automatically covered, but I have heard of people motivating for one. The trouble there is that even if you get the pump, they don’t always cover the monthly consumables (on top of the insulin) so you may have to pay for that yourself. You can find out if you’re ready for an insulin pump here.

Again, this is just one perspective – let me know if you’d like me to open up the conversation!
Have a lovely day,
Bridget