Prescribed Minimum Benefits: The Full Picture

When we think about healthcare, mental health is often overlooked or not taken seriously, yet it is just as important as our physical well-being. For many people in South Africa, the cost of ongoing mental health treatment, whether that’s therapy, medication or hospital care, can be a barrier to getting much needed support. This is where Prescribed Minimum Benefits (PMBs) come in. PMBs ensure that everyone on a medical aid scheme has access to treatment for ‘essential’ health conditions, including some mental health challenges like depression.

What makes PMBs so important (and appealing) is that they take away some of the worry about how to afford care, making it easier for individuals to focus on healing. However, like any system, there are both advantages and challenges. When it comes to mental health, navigating these benefits can feel complicated, and people often find themselves unsure about what’s covered and how to access the right support. Others may be unaware of the consequences of having a PMB too.

In this post, we’ll explore the impact on PMBs on mental health care. From how they help, where they fall short, and what PMBs mean for individuals seeking support for their mental well-being and future.

What are PMBs exactly and how do they relate to mental health?

PMBs are a set of health services that every medical aid scheme in South Africa is legally required to cover. The aim of PMBs is simple: to make sure that no matter which medical aid plan you’re on, you have access to treatment for critical health conditions. This includes emergency care, chronic illnesses, and a list of over 200 medical conditions.

When it comes to mental health, PMBs ensure that certain conditions, such as major depressive disorder, are covered to an extent. This means that individuals dealing with particular types of mental health difficulties are entitled to receive certain amounts of treatment, from medication to therapy, without having to worry about whether their medical aid will pay for it. PMBs play a crucial role in mental health care, as they cover specific conditions which often require long-term treatment and consistent support. Thus, PMBs can offer some financial relief while the individual receives the support they need. PMBs are also renewed yearly.

For example, someone living with bipolar disorder might need regular psychological care and medication to stablise their mood. Without a PMB (which needs to be motivated by a registered healthcare professional), these costs can quickly become unmanageable. But with a PMB, medical schemes are required to cover a portion of these ongoing treatment expenses.

However, while PMBs can ensure access to care, there are still limits and complications that can come with receiving this type of support.

Benefits of a PMB

1. Access to Mental Health Treatment

One of the biggest advantages of PMBs is that they provide access to necessary mental health care. Some mental health conditions can be debilitating, but PMBs ensure that medical aid members can receive treatment without worrying too much about coverage.

• Comprehensive Coverage for Chronic Mental Health Conditions

Mental health conditions often require long-term treatment and ongoing management. PMBs can provide coverage for chronic conditions ensuring that individuals can access the treatment they require to maintain stability over time. This type of long-term support can help reduce the likelihood of relapses, hospitalisations, or crises that may arise if care were interrupted due to financial limitations.

• Reduced Financial Stress

Mental health difficulties often go hand-in-hand with financial stress, as ongoing therapy and medication costs can add up quickly. By covering essential treatments, PMBs help reduce the financial burden on individuals and families, alleviating the pressure that often comes with the ongoing costs of therapy, medication and hospital stays.

• Hospital Cover for Mental Health Reasons

In cases where mental health conditions become severe, hospitalisation may be necessary. PMBs ensure that emergency care, including hospitalisation for a mental health crisis, is covered by medical aids. This provides an added layer of protection for individuals who may experience acute episodes that require intensive treatment.

Limitations of PMBs

1. Limited Range of Mental Health Conditions Covered

While PMBs ensure coverage for several severe mental health conditions, they do not extend to all mental health conditions. Conditions like adjustment disorders, anxiety disorders, or personality disorders may not be fully covered under PMBs.

• Restricted Number of Therapy Sessions

Although PMBs cover therapy for certain mental health conditions, the number of therapy sessions allowed is often limited. This typically includes 15 out-patient sessions, which are then shared between healthcare professionals, such as psychiatrists and psychologists. Mental health healing and recovery, often requires long-term or ongoing therapeutic support, but individuals may find that the number of sessions covered by the PMB are insufficient for their needs.

• Complex Approval Process

Accessing PMB benefits is not always straightforward. Individuals may have to navigate complex approval processes or submit additional documentation to get their treatments covered. The back-and-forth between medical aids, healthcare providers, and individuals can delay treatment, exacerbating symptoms and adding stress to an already difficult situation.

The Limitations that Aren’t Really Spoken About

1. The Permanent Nature of a PMB Diagnosis

A controversial aspect of a PMB, especially in relation to mental health, is the fact that once a condition is diagnosed and covered by a PMB, that diagnosis is often permanent. This means that the diagnosis becomes part of the individuals medical record indefinitely, even if their condition improves significantly or they no longer require active treatment. It is incredibly difficult to have that diagnosis “removed” from one’s medical history, even if the individual makes a full recovery. This is especially true for conditions like depression, where symptoms can vary over time and may not always require ongoing treatment.  While this permanence is beneficial as PMBs are renewed yearly and allows continued access to treatment, it can also have unintended consequences.

• The Impact on Insurance Policies

While PMBs focus on ensuring access to essential healthcare, they can influence life and health insurance policies as well as Disability Cover. For individuals with mental health conditions covered under PMBs, such as depression, the fact that they are receiving treatment through their medical aid can be seen by insurance companies as an indicator of higher risk. This may lead to higher premiums or even exclusions for certain conditions.

Note: Insurers may request a Personal Medical Attendants Report (PMA) which is completed by the individual’s healthcare provider. A PMA helps insurers assess the risk associated with insuring an individual, based on their medical history and currently health status.

• Possible Career Exclusions

Although in South Africa the Employment Equity Act prohibits unfair discrimination against individuals based on disabilities, including mental health conditions, it is important to understand how a PMB diagnosis could possibly limit career choices. For example, if one wants to become a pilot, the South African Civil Aviation Authority (SACAA) have a specific set of physical and mental health standards to ensure safe flying. If their assessment protocol is administered and individuals do not meet their specific standards, one might not be able to become a pilot. Other professions, such as armed forces and law enforcement also have particular standards that need to be met.

Note: It is very important to note that having a mental health condition does not automatically exclude individuals from these careers. Each case is assessed individually, and various factors are considered.

While PMBs can offer significant support for those managing mental health conditions, the complexities surrounding coverage and treatment options can vary from person to person. Healthcare needs are unique to each individual and what works for one, might not be the best option for another. Therefore, it is absolutely essential to consult with a healthcare provider when considering treatment plans and whether a PMB is right for you. Healthcare professionals can help clarify which treatments are covered, assist with navigating the approval process, and provide guidance on long-term care options tailored to your specific needs.

Making informed decisions about your mental health care is vital for both your well-being and peace of mind. Working with your healthcare provider ensures that you have all the information and professional support you need to make the best choices for your health and future.