The Council for Medical Schemes (CMS) seeks to provide clarity regarding the funding of Iron Deficiency Anaemia as a Prescribed Minimum Benefit (PMB) condition.
The PMB Regulations specify that Iron Deficiency Anaemia is a PMB condition under Diagnosis and Treatment Pair (DTP) code 236K. DTP code 236K refers to Iron deficiency; vitamin and other nutritional deficiencies – life-threatening. Considering this DTP code descriptor, all forms of Iron Deficiency Anaemia (acute or chronic) are PMB conditions.
The treatment component specified for this DTP, according to the PMB Regulations, is medical management. Any member who has Iron Deficiency Anaemia must be provided with PMB funding for the diagnosis, treatment, and care costs of this condition in line with the PMB Regulations.
It is important to note that the medical schemes are expected to apply protocols to make PMB funding decisions in line with Regulation 15H of the Medical Schemes Act (131 of 1998), which specifies that if managed health care entails the use of a protocol –
such protocol must be developed based on evidence-based medicine, taking into account considerations of cost-effectiveness and affordability;
the medical scheme and the managed health care organisation must provide such protocol to health care providers, beneficiaries and members of the public, upon request; and
provision must be made for appropriate exceptions where a protocol has been ineffective or causes or would cause harm to a beneficiary, without penalty to that beneficiary.
The CMScript on Iron Deficiency Anaemia is therefore amended in line with the PMB descriptor for DTP code 236K to ensure that there is consistency in the interpretation and application of the PMB Regulations and thereby ensuring that members are provided with the necessary funding for this PMB condition.