PMB's And DSP's go hand in hand

When trying to obtain treatment for a prescribed minimum benefit (PMB) condition, you may come across terms like "designated service provider" and "co- payment". This monthwe concentrate on what these mean for you.

What is a designated service provider?
A designated service provoder or DSP is a healthcare provider (doctor, pharmacist, hospital, etc) who is appointed by your medical scheme to treat or care for prescribed benefit (PMB) conditions of their members.

State healthcare facilities can be DSP's too but before they can be listed as such in the rules of your medical scheme, your scheme must make sure that you and it's other beneficiaries can reach these facilities with reasonable ease and that the required treatment, medication, and care are both available and accessible.

What is a co- payment?
A co- payment is the amount of money or portion of the account that your scheme may request you to fund your own pocket. This could be either a percentage of the fee or the difference between the tariff of your scheme's chosen DSP and the amount charged by the provider (non- DSP) you went to. The co- payment amount must be specified in the scheme rules.

When can the scheme charge a co- payment?
You can use a non- DSP if you want to (voluntarily) but there may be times when you will have no choice but to use a non- DSP. If you choose to voluntarily use a non- DSP for your PMB condition, you may have to pay a protion of the bill as a co- payment.

What is involuntary use of a non- DSP?
If circumstances force you to obtain a service from a non- DSP (i.e. involuntarily) and it's a PMB condition, your scheme must pay for the costs of the treatment, diagnosis, and care in full. These are the reasons why you may need to obtain treatment from a DSP- involuntarily

• the required service or treatment is not really available from your scheme's DSP or it will be provided with unreasonable delay;
• an emergency occurs under circumstances or at a location that prevents you from obtaining PMB treatment from a DSP; or
• there is no DSP within a reasonable proximity to your ordinary place of business or personal residence

What are PMB's?
Perscribed Mininum Benefits (PMB's) are a set of defined benefits to ensure that all medical schemes have access to certain minimum health services, regardless of the benefit option they have selected. Medical Schemes have to cover the costs related to the diagnosis, treatment and care of:

• Any emergency condition (http://www.medicalschemes.com/medical_schemes_pmb/emergency_medical_conditions.com)
• A limited set of 270 medical conditions (http://www.medicalschemes.com/medical_schemes_pmb/conditions_covered.htm);
• and 25 chronic conditions
• (http://www.medicalschemes.com/medical_schemes_pmb/chronic_disease_list.htm)

How does treatment at DSP's work?
Your scheme can insist that you go to a DSP, this is not entirely correct as the DSP should be used for the diagnosis as well as soon as your PMB condition is diagnosed, in which case they cover the costs from the start. When your condition is identified as a PMB after diagnosis, your scheme must pay for the tests and treatment in full retrospectively. Treatment for a PMB condition at a DSP is covered in full by the medical scheme.

Health Warning

Be very cautious before cancelling an existing risk policy or allowing a policy to lapse by stopping your premiums. You may not be offered the same terms you had on you had on your original policy, particularly if your risk status has changed – for example, after a deterioration in health.


If your risk status has changed dramatically – for example, if you have contracted a terminal disease – you may be refused cover altogether.

Risk assurance has become very competitive, with the result that it has also become more complex as life assurance companies try to differentiate on product design.

The increased competition has also seen some life assurance companies luring top sales staff from other companies with perverse incentives, which could see these advisors acting in their own interest and that of their new employers rather than yours.

You need to be cautious when a financial advisor suggests that you switch insurance companies – the move may or may not be in your best interest.

Be particularly wary of products that have lower premiums now but allow for significant or vague increases in the future. You may find the future premium increases become prohibitive but you may not be able to change to another company because of the deterioration of your health.