Cover for Prescribed Minimum Benefits

As an Engen Medical Benefit Fund member, you have cover for Prescribed Minimum Benefits (PMBs). They are a set of defined benefits to make sure that all medical scheme members in South Africa have access to certain minimum healthcare services. The aim is to give members access to cover for continuous care to improve their health and wellbeing and to make healthcare more affordable. PMBs are defined and governed by the Council for Medical Schemes (CMS) and the Medical Schemes Act 131, 1998.

What we pay for

The Prescribed Minimum Benefits (PMB) Chronic Disease List (CDL) is a list of conditions which all medical schemes must cover. Your cover includes funding for the diagnosis, treatment, and ongoing care for the listed conditions. These services include approved treatment, medicine, consultations, blood tests and other defined tests. We pay for these healthcare services as PMBs, and it will not affect your day-to-day benefits.

PMBs are also guided by a list of medical conditions as defined in the Medical Schemes Act. According to this, all medical schemes must cover the diagnosis, treatment and care costs related to:

• Emergency medical conditions
• A defined list of 271 diagnoses
• 26 chronic conditions (Chronic Disease List conditions).

Click here to learn about what procedures, tests and consultations we cover for the diagnosis and ongoing management for each PMB condition. You can also learn more about the applicable medical conditions on the PMB list.

Use the Fund's designated service providers (DSPs) for full cover

Designated service providers (DSPs) are healthcare professionals with whom we have a payment arrangement. These healthcare professionals have agreed to provide treatment or services to our members at a contracted rate.

If you do not use a DSP, we will pay up to 100% of the Fund Rate. You will then be responsible for the difference between what we pay and the actual cost of your treatment, which means you will have to make a co payment.

To avoid co-payments when you use the services of a GP or Specialist, you must go to a GP or Specialist in the Fund's designated service provider (DSP) networks. In addition, you must be admitted to a hospital in the Fund's PMB network of hospitals to make sure all the costs for PMB treatment in a hospital are paid in full.

When you don't have time to look for a designated service provider (DSPs)

In a medical emergency, you can go directly to hospital and notify the Fund of your admission as soon as possible. You are covered in full for the first 24 hours or until you are stable enough to be transferred to a DSP if it is a medical emergency, i.e., your condition is life threatening and you need immediate care.

Keep in mind that we pay for treatment not included in the PMBs from your available benefits (where appropriate) and according to the rules of the Fund.

How to find designated service providers (DSPs)

To search for a service provider that is in our networks closest to you, click here.

What to do if there is no available designated service provider (DSP)

There are some instances when you will still have full cover if you use a healthcare provider who is not a designated service provider (DSP). In a medical emergency or when the use of a non designated service provider (non-DSP) is involuntary, or when there is no DSP available.

In cases where there are no services or beds available at a designated service provider (DSP) when you or one of your dependants need treatment, you can contact us on 0800 001 615. We will arrange for an appropriate facility or healthcare provider to accommodate you.

Your cover for chronic (long-lasting) conditions on the Chronic Illness Benefit

We want to help you to be as healthy as possible. The Chronic Illness Benefit (CIB) pays for specific medicine, tests and doctor's visits once you register your chronic condition with us. This means you get to keep your day to day medicine benefit for unexpected illnesses.

Keep in mind that you should go to one of the Fund's network providers for your treatment and care if you want the Fund to pay your claims in full. This includes network pharmacies.

How we pay for medicine from the Chronic Illness Benefit

The Chronic Illness Benefit covers authorised medicine for the 26 Prescribed Minimum Benefit (PMB) Chronic Disease List (CDL) conditions.

Authorised medicine for your approved PMB condition that appears on the Fund's formulary (list of medicines to treat the condition) will be funded in full up to the Fund Rate. Medicines that do not appear on the formulary will be funded up to the Maximum Medical Aid Price (MMAP) or Fund Rate in the absence of the MMAP.

For ADL conditions, there is no list of medicine. We pay for approved medicines for these conditions up to the MMAP or Fund Rate in the absence of MMAP.

The Fund uses the MMAP, a guide detailing the maximum price medical schemes will pay for an interchangeable multi-source pharmaceutical product (generic product).

You can get details of the Chronic Disease List on the Fund's website at www.engenmed.co.za.

If your condition is one of the CDL or if you use non-PMB medicine continuously for more than 3 months and you meet the clinical entry criteria, you can register on the Chronic Illness Benefit. You may have to get specific tests done and submit the results to us to prove that you have the condition to qualify.

How to register

You can register in one of three ways:

1. If your treating doctor is part of our network, they can use HealthID (the healthcare professionals' platform) to register for the Chronic Illness Benefit on your behalf. You must give your consent before your doctor can start the process.
2. You and your treating doctor can complete the Chronic Illness Benefit application form and send it to us. You can download the Chronic Illness Benefit application form from the Fund's website at www.engenmed.co.za.
3. You can phone 0800 001 615 to register, or your doctor can phone 0860 44 55 66 to register your condition.

To avoid co-payments (additional payments which you must pay yourself) and get the most out of your benefits, make sure your doctor is one of our designated service providers.