Prescribed Minimum Benefits &

Chronic Medication

COUNCIL FOR MEDICAL SCHEMES

Prescribed Minimum Benefits (PMB’s)

• All medical schemes have to provide a basic set of benefits known as Prescribed minimum benefits- “270 treatment pairs”

• Schemes to pay the full cost of diagnosis, treatment and care thereof.

• Each option offered by a medical scheme must make provision for the PMB’s.

Objectives of the Prescribed Minimum Benefits

• Protects consumers from invisible limits to necessary benefits

• Prevent unfair discrimination on selected benefits

• Protect cover for necessary and high cost services

• Prevent dumping on the public health system

• Promote more appropriate behavior in benefit design, costing and management of cost

Preamble to Regulations

• “The objective of specifying a set of Prescribed Minimum Benefits within these regulations is two fold:

1. To avoid incidents where individuals lose their medical scheme cover in the event of serious illness and the consequent risk of unfunded utilization of public hospitals.

2. To encourage improved efficiency in the allocation of Private and Public health care resources”

The 15 PMB categoriesPMB Category Example

Brain and nervous system StrokeEye GlaucomaEar, nose, mouth and throat Cancer of oral cavity, pharynx, nose, ear, and larynxRespiratory system PneumoniaHeat and vasculature (blood vessels) Heart attacksGastro-intestinal system AppendicitisLiver, pancreas and spleen Gallstones with cholecystitisMusculoskeletal system (muscles and bones); Trauma NOS

Fracture of the hip

Skin and breast Treatable breast cancerEndocrine, metabolic and nutritional Disorders of the parathyroid glandUrinary and male genital system End stage kidney diseaseFemale reproductive system Cancer of the cervix, ovaries and uterusPregnancy and childbirth Antenatal and obstetric care requiring hospitalisation,

including delivery

Haematological, infectious and miscellaneous systemic conditions

HIV/Aids and TB

Mental illness ShizophreniaChronic conditions Asthma, diabetes, epilepsy, hypothyroidism,

schizophrenia, glaucoma, hypertension

HIV/AIDS PMB

• Diagnosis: HIV infection• Treatment:

– HIV voluntary counseling and testing– Co-trimoxazole as preventive therapy– Screening and preventive therapy for TB– Diagnosis and treatment of STIs– Pain management in palliative care– Treatment of opportunistic infections– Prevention of mother-to-child transmission of HIV – Post-exposure prophylaxis following occupational

exposure or sexual assault

• Care : ARV’s

Applications

• Regulation 8 (1 January 2004) specifies:

(1) Subject to the provisions of this regulation, any benefit option that is offered by a medical scheme must pay in full, without a co-payment or the use of deductibles, the diagnosis, treatment and care costs of the prescribed minimum benefit conditions

Chronic diseases• 25 chronic diseases are included in the 270

PMB conditions• Treatment algorithms were developed:

– to manage risk– to ensure appropriate treatment standards– treatment covered by schemes may not be

inferior to the algorithms• Consultations & tests are also covered• Protocols, formularies & designated service

providers may be used to manage risk

Chronic Disease List Addison’s Disease Asthma Bipolar Mood Disorder Bronchiectasis Cardiac Failure Cardiomyopathy Chronic Renal Disease Chronic Obstructive

Pulmonary Disease Coronary Artery Disease Crohn’s Disease Diabetes Insipidus Diabetes Mellitus Type 1 & 2

Dysrythmias Epilepsy Glaucoma Haemophilia Hyperlipidaemia Hypertension Hypothyroidism Multiple Sclerosis Parkinson’s Disease Rheumatoid Arthritis Schizophrenia Systemic Lupus

Erythematosus Ulcerative Colitis

CDL: What members need to know

• Schemes can demand pre-authorisation or the joining of a benefit management programme

• Schemes may decide for which medicines it will pay, as long as they are at least on par with the published treatment standards

• Chronic medicine limits can still be set, but if limits are exhausted, schemes have to continue paying for chronic medication obtained from DSPs

Can my scheme refuse to cover my medication if I need, or want a brand

other than that which the scheme says it will pay for?

The scheme may refuse to cover all the expenses.

When a formulary drug is clinically appropriate and effective; and the beneficiary knowingly declines; and ops to use another drug instead, the scheme may impose a co-payment

Yes, your scheme can set a limit for chronic medication, however if you exhaust the set limit for chronic medicine your scheme will have to continue paying for any chronic medication you obtain from its designated service provider for a PMB condition.

Can schemes still set a chronic medicine limit?

Legal Framework

• Regulation 8 (1 January 2004) specifies:

(1) Subject to the provisions of this regulation, any benefit option that is offered by a medical scheme must pay in full, without a co-payment or the use of deductibles, the diagnosis, treatment and care costs of the prescribed minimum benefit conditions

Legal Framework

Managed Care Interventions

(4) Medical schemes may employ…. appropriate interventions such as …. pre-authorisation, treatment protocols, formularies, etc.

Formularies

(5) When a formulary drug is clinically appropriate and effective; and the beneficiary knowingly declines; and ops to use another drug instead, the scheme may impose a co-payment

15 H Protocols and 15 I Formularies:

(a) … must be developed on the basis of evidence-based medicine, taking into account considerations of cost-effectiveness and affordability…

(b) ….must provide such protocol / formulary to health care providers, beneficiaries and members of the public, upon request,…

(c) Provision must be made for appropriate exceptions / substitution…has been ineffective of causes or would cause harm to a beneficiary, without penalty to that beneficiary.

Legal Framework

Co-payments

• Co-payments can be levied if members choose to use non-formulary medication and/or non-designated service providers

• Co-payments must be approved in rules • Quantum to relate to difference between

actual costs and preferred provider / reference price of formulary drug

• Co-payments may not be recovered out of savings accounts

What is a designated service provider?

It is a healthcare provider/s (doctor, pharmacist, hospital etc) which is chosen by your medical scheme to be utilised as a preferred provider to its members when they need diagnosis, treatment or care for a PMB condition.

The role of Designated Service Providers (DSPs)

• DSP = medical scheme’s 1st choice provider for PMB condition treatment

• May be state facilities, but not necessarily• Scheme responsibilities:

– ensure accessibility– ensure DSPs can deliver required services

• Non-DSP services are covered when:– DSPs are not accessible– DSPs cannot deliver– Emergency treatment is required

DSPs: Prevailing practices

• Schemes designate the public sector as DSP without ensuring reasonable availability & accessibility of services

• PMB service provision not arranged with public sector

• Responsibility to secure a bed in the public sector is shifted to beneficiaries

• Promoting unfunded utilisation of services in the public sector

• Members not fully informed about their DSP setting, particularly when it is the public sector

Proposed model for reimbursement of Prescribed

Minimum Benefits

Obtained from a designated (contracted)

service provider (public/private)?

YES

NO

NO co-payment

Voluntary

Involuntary

Co-payments

No co-payments

The message to your constituents

1. Confirm with your scheme that your condition is a PMB

2. Obtain the applicable rules from your scheme, i.e. protocols, formularies, DSPs, co-payments

3. Make sure your GP/specialist manage your treatment in terms of PMB rules & provisions

4. Adhere to your medical scheme’s rules applicable to your condition

5. Be an active consumer: ask questions, obtain 2nd opinions, follow the complaints procedure

You could appeal

• If formulary medication is not effective beneficiaries can appeal to their schemes to approve alternative treatment

• Doctor needs to provide clinical history

• If successful, scheme will cover non-formulary treatment in full

• NOTE: personal preference is not grounds for appeal

THANK YOU!