Prescribed Minimum Benefit Conditions
In terms of the Medical Schemes Act 131 of 1998 and its Regulations, all medical schemes have to cover the costs related to the diagnosis, treatment and care of:
- An emergency medical condition
- A defined list of 270 diagnoses
- A defined list of 25 chronic conditions
TO ACCESS PRESCRIBED MINIMUM BENEFITS, THERE ARE RULES THAT APPLY:
- Your medical condition must qualify for cover and be part of the defined list of Prescribed Minimum Benefit (PMB) conditions.
- The treatment needed must match the treatments in the defined benefits.
- You must use designated service providers (DSPs) in our network if applicable to your plan.
This does not apply in emergencies. However, even in these cases, where appropriate and according to the rules of the Scheme, you may be transferred to a hospital or other service providers in our network once your condition has stabilised.
If your treatment doesn’t meet the above criteria, the Scheme can apply co-payments or pay for PMBs at Scheme rates.
You will be responsible for the difference between what the Scheme pays and the actual cost of your treatment.
PMB claims for Custom and Essential options members will be paid at the Scheme rates, as these options are exempt from the PMBs.
WHAT IS AN EMERGENCY?
An emergency medical condition, also referred to as an emergency, is the sudden and, at the time unexpected, onset of a health condition that requires immediate medical and surgical treatment, where failure to provide medical or surgical treatment would result in serious impairment to bodily functions or serious dysfunction of a bodily organ or part or would place the person’s life in serious jeopardy. An emergency does not necessarily require a hospital admission. We may ask you for additional information to confirm the emergency. For emergency assistance, please call 0861 009 353.
You get extensive cover for chronic conditions
MHC members living with a chronic illness get the best care when they register on the Chronic Care Programme.
The programme grants you free access to treatment for a list of medical conditions under the Prescribed Minimum Benefits (PMBs). The PMBs cover 26 chronic conditions on the Chronic Disease List (CDL). Some of our plans cover conditions that are richer than the PMBs, and cover depends on the plan you choose.
Chronic Illness Benefit
This benefit covers you for a defined list of chronic conditions. You need to apply to have your medicine covered for your chronic condition. Refer to page 24/25 for additional info (process flow).
Medicine cover for the Chronic Disease List (CDL)
You get full cover for approved chronic medicine on our list. For medicine not on our list, you may incur a co-payment. Refer to page 12 for additional information.
Medicine cover for the Additional Disease List
If you on the Optimum plan we cover an additional 28 conditions while the Classic and Classic Network plans cover 10 conditions for medicine on the Additional Disease List (NON-PMB Conditions).
How do we pay for medicine?
We pay for medicine up to the maximum of the Moto Health Care (MHC) rate including the fee for dispensing it.