THE PRESCRIBED MINIMUM BENEFITS JOURNEY

As your medical scheme, TFGMAS talks about 'Prescribed Minimum Benefits' or 'PMBs' quite often. These are treatments we pay for without using your day-to-day benefits, but there are conditions and limits to cover. To limit out-of-pocket payments or payments from your day-to-day benefits, TFGMAS makes available a PMB Network of doctors, specialists, pharmacies and hospitals to its members.

WHAT ARE THE BASICS?

We pay for Prescribed Minimum Benefit treatment without using your ordinary day-to-day benefits (no matter your chosen benefit plan) as long as you meet the three conditions for full cover:

You are diagnosed with a condition on the Prescribed Minimum Benefit list.
You follow the treatment in the Prescribed Minimum Benefit guidelines. If you and your doctor use another treatment, we pay for it from your available benefits.
You use our designated service providers, that is doctors, specialists, pharmacies and hospitals in the PMB Network.

HOW WOULD THESE BENEFITS WORK?

To ensure you are fully covered for PMB conditions, the enclosed "Member Journey Map" aims to map out the journey that you as a member may need to follow should you need to obtain treatment for a PMB condition.

Let's take Lesedi as an example.

GETTING TO A DOCTOR

Lesedi wakes up one morning to incredibly painful stomach cramps and realises that she needs medical help as soon as possible. She uses the TFG Medical Aid Scheme app to find a GP in the network who is close to her home and calls the doctor's practice. She explains the situation to the receptionist and makes an appointment. She's tempted to look up the closest specialists as well, but the GP has to diagnose her and discuss her treatment with her before they can decide what to do next.

AT THE GP'S ROOMS

Lesedi gets to the GP's rooms a little before her appointment so she has time to fill in forms. She shows the receptionist her ID and membership card to confirm she is a member of TFGMAS. Lesedi is in a lot of pain and is relieved to see the GP. He asks her about her symptoms, her health, her medicine and so on before he examines her. While the doctor is calm and professional, it's clear that something is seriously wrong. He wants her to have an X-ray done. Lesedi reminds the GP that she's on TFGMAS, so he fills in a form to refer her to a radiologist in TFGMAS's network.

THE X-RAY CLEARLY SHOWS THE PROBLEM

Lesedi experiences waves of pain while she waits for her X-rays. The radiologist takes the X-ray. Lesedi will have to wait for the GP to tell her what the results of the X-rays taken are. When the doctor reads the report and looks at the X-rays, he tells Lesedi that he's seen her problem before. He remarks that they usually catch it earlier. To her surprise, she's expecting a baby and needs an emergency caesarean!

HOSPITAL ADMISSION

Because it's a medical emergency, the GP sends Lesedi to the closest hospital with an obstetrician gynaecologist (OBGYN). Out of habit, Lesedi asks the GP if the hospital and the specialists will be in TFGMAS's PMB Network. As this is an emergency she can go to any hospital but for a planned procedure, Lesedi would have had to go to a Mediclinic hospital. While she's used to the idea of using networks, she's still getting used to the idea of having a baby. The GP tells her not to worry about this since treating an emergency medical condition is a Prescribed Minimum Benefit. He does know the hospital is in the network though. At the hospital, Lesedi meets the OBGYN and the anaesthetist. She's still worried that her accounts won't be paid in full, but her focus now is on having her baby and dealing with the pain.

LEAVING THE HOSPITAL AND MEDICINE

Luckily, the baby is healthy and they can soon go home. Lesedi uses the Scheme app to find a pharmacy that is a designated service provider. She's tired so she just asks the pharmacy to fill her prescription without asking about generic medicine or checking TFGMAS medicine list.

MEDICAL ACCOUNTS

Since Lesedi didn't know she was expecting a baby, she also doesn't know what to expect from her medical accounts since she couldn't get preauthorisation ahead of time. She hopes she won't have to spend too much money on the part of the bills TFGMAS doesn't pay (deductibles).

She carefully goes through her claims statement and checks how much the Scheme paid and how much she has to pay herself.

Here's what she finds:
The hospital was a network hospital, so TFGMAS paid the network rate. She doesn't have to pay in.

Because she visited a GP in the PMB Network, TFGMAS paid the entire account.
The X-ray account was charged at more than the Scheme Rate, but the radiologist adjusted their account to fit the network agreement. Lesedi doesn't have to pay in for the account.
TFGMAS paid the claim from the OBGYN and anaesthetist at cost, because getting treatment was a medical emergency and so it doesn't make a difference to Lesedi that they weren't part of the PMB Network. She doesn't have a deductible.
Because Lesedi didn't get medicine on TFGMAS's medicine list, TFGMAS only paid up to the Scheme Rate and she has to pay the rest of the account herself.

Lesedi is relieved to have had most of her accounts paid and having made use of TFGMAS's PMB Network and designated service providers, all her accounts related to her PMB condition were paid and settled. She can now focus on getting well, and adjusting to her unexpected baby!

PMB MEMBER JOURNERY MAP