Prescribed Minimum Benefits (PMBs) in South Africa: What Must Be Covered? A Plain-English Guide

Prescribed Minimum Benefits (PMBs) are the cornerstone of healthcare protection in South Africa. 

Established to ensure that medical scheme members have access to a minimum level of essential health services regardless of their chosen benefit option, PMBs act as a vital safety net. 

This guide provides a comprehensive, plain English breakdown of what PMBs are, what they cover, and how you can ensure your medical aid honours its legal obligations.

Why PMBs Exist: The Purpose of the Mandate

The concept of Prescribed Minimum Benefits was introduced to solve a critical problem in the South African healthcare landscape. Before PMBs, many medical scheme members would find themselves without cover for serious, life-threatening conditions once their annual limits were reached. 

This often forced individuals to rely on the already burdened public health system. By mandating a minimum level of cover, the government ensured that members are protected from the financial devastation of catastrophic health events. 

Furthermore, PMBs ensure that medical schemes remain sustainable by preventing “cherry-picking”, where schemes only cover healthy individuals, and ensuring that all members contribute to a pool that covers essential care for everyone.

What are Prescribed Minimum Benefits?

At its core, a PMB is a legally mandated set of health conditions and treatments that every registered medical scheme in South Africa must cover. 

This requirement is non-negotiable and applies to every single plan, from the most basic hospital-only option to the most expensive comprehensive suite. 

The primary goal of PMBs is twofold: to protect members from the financial ruin that often accompanies serious or chronic illness, and to ensure that the public health system is not overwhelmed by members who have private cover but run out of benefits.

The Legal Foundation: The Medical Schemes Act

PMBs are not a “feature” offered by medical aids; they are a statutory requirement under the Medical Schemes Act No. 131 of 1998. 

The Council for Medical Schemes (CMS) is the regulatory body responsible for overseeing medical schemes and ensuring they comply with these regulations. 

If a condition is classified as a PMB, the scheme must pay for its diagnosis, treatment, and care in full, provided the member follows the scheme’s rules regarding service providers and medication protocols.

The Three Pillars of PMB Coverage

PMB coverage is divided into three distinct categories, each covering a different aspect of healthcare.

1. Medical Emergencies

A medical emergency is defined as the sudden and, at the time, unexpected onset of a health condition that requires immediate medical or surgical treatment. 

For a condition to be classified as an emergency PMB, failure to provide immediate treatment must result in serious impairment to bodily functions, serious dysfunction of a body organ or part, or would place the person’s life in serious jeopardy.

Common examples include:

• Heart attacks and strokes.
• Severe trauma (e.g., major car accidents).
• Acute respiratory failure.
• Poisoning or severe allergic reactions (anaphylaxis).

In a true emergency, you should go to the nearest hospital, whether it is a “network” hospital or not. The scheme is legally required to cover the costs of stabilising you. 

Once you are stable, the scheme may request that you be transferred to one of their Designated Service Providers (DSPs).

2. The Chronic Disease List (CDL)

The CDL is a list of 27 chronic conditions for which every medical scheme must provide cover for diagnosis, medical management, and medication. These conditions are:

1. Addison’s Disease
2. Asthma
3. Bipolar Mood Disorder
4. Bronchiectasis
5. Cardiac Failure
6. Cardiomyopathy
7. Chronic Renal Disease
8. Chronic Obstructive Pulmonary Disease (COPD)
9. Coronary Artery Disease
10. Crohn’s Disease
11. Diabetes Insipidus
12. Diabetes Mellitus Type 1
13. Diabetes Mellitus Type 2
14. Dysrhythmias
15. Epilepsy
16. Glaucoma
17. Haemophilia
18. HIV/AIDS
19. Hyperlipidaemia (High Cholesterol)
20. Hypertension (High Blood Pressure)
21. Hypothyroidism
22. Multiple Sclerosis
23. Parkinson’s Disease
24. Rheumatoid Arthritis
25. Schizophrenia
26. Systemic Lupus Erythematosus
27. Ulcerative Colitis

For these conditions, the scheme must cover the cost of the consultations with your doctor, the necessary blood tests or scans, and the chronic medication required to manage the condition.

3. Diagnosis and Treatment Pairs (DTPs)

This is the largest category, consisting of approximately 270 groups of conditions. DTPs cover a wide range of serious illnesses, many of which require hospitalisation. 

The “pair” refers to a specific diagnosis linked to a specific treatment. For example, if you are diagnosed with a specific type of cancer, the DTP specifies the minimum level of surgery, chemotherapy, or radiation that the scheme must cover.

DTPs include:

• Most cancers (oncology).
• Serious infections like meningitis or pneumonia.
• Surgical procedures like appendectomies or hip replacements (under specific clinical criteria).
• Maternity care, including complications during pregnancy and childbirth.

Understanding Designated Service Providers (DSPs)

A Designated Service Provider is a healthcare provider (doctor, pharmacist, or hospital) that has an agreement with your medical scheme to provide treatment and clinically appropriate medicines at a set rate.

Why DSPs Matter

To manage costs, schemes are allowed to insist that you use their DSPs for PMB treatments. 

If you voluntarily choose to use a provider who is not a DSP, the scheme may charge you a co-payment or only pay up to their standard rate, leaving you to pay the difference.

Exceptions to the DSP Rule

There are three specific instances where a scheme must pay in full even if you use a non-DSP:

1. Emergencies: If the condition was a true emergency and no DSP was available or accessible in time.
2. No DSP Available: If the scheme does not have a DSP in your area, or if the DSP cannot provide the required treatment within a reasonable timeframe.
3. Involuntary Use: If you were unconscious or otherwise unable to choose a provider.

The Role of Formularies and Protocols

Medical schemes use “formularies” (lists of approved medicines) and “clinical protocols” (standardised treatment plans) to manage PMB costs.

• Formularies: The scheme will have a list of medicines it covers for each CDL condition. Usually, these are generic versions of well-known drugs. If you choose to use a brand-name drug not on the formulary, you may have to pay a co-payment.
• Protocols: These are the “rules” for treatment. For example, a protocol might state that you are entitled to two specialist visits and four blood tests per year for a specific condition. If your doctor wants more, they must provide a “medical motivation” to the scheme.

Eligibility, Waiting Periods, and Penalties

PMBs apply to every member, but there are some nuances regarding when coverage starts.

• General Waiting Periods: When you join a scheme, they can apply a 3-month general waiting period. During this time, you are not covered for anything, including PMBs, unless it is a life-threatening emergency.
• Condition-Specific Waiting Periods: If you have a pre-existing condition, the scheme can exclude cover for that condition for up to 12 months. However, after that 12-month period, they must cover it as a PMB if it falls on the CDL or DTP list.
• Late Joiner Penalties: If you join a medical scheme later in life without having had previous cover, you may face a permanent monthly penalty. This penalty does not affect your PMB rights; it only affects your premium.

How to Access Your PMB Benefits: A Step-by-Step Guide

To ensure your claims are paid from the PMB benefit and not your savings or daily benefits, follow these steps:

1. Confirm the Diagnosis: Ask your doctor if your condition is on the CDL or DTP list.
2. Register the Condition: Most schemes require you to complete a “Chronic Illness Benefit” (CIB) application form. Your doctor will need to provide the ICD-10 code (a specific medical code for your diagnosis).
3. Obtain Pre-Authorisation: For hospital stays or expensive treatments, always call your scheme to get an authorisation number. Explicitly ask if the treatment is being authorised as a PMB.
4. Use DSPs: Check your scheme’s website or app to find the nearest network doctors, pharmacies, and hospitals.
5. Check the Formulary: Ensure your prescribed medication is on the scheme’s approved list. If your doctor insists on a non-formulary drug, ask them to write a motivation explaining why the formulary drug is not suitable for you.

What to Do if a PMB Claim is Rejected

It is not uncommon for PMB claims to be incorrectly processed. If your claim is rejected or paid from your savings:

1. Check the ICD-10 Code: Ensure the doctor used the correct code on the invoice.
2. Request a Reason: Ask the scheme for a written explanation of why the claim was not paid as a PMB.
3. Internal Appeal: Every scheme has an internal disputes committee. Submit a formal appeal with your doctor’s supporting evidence.
4. Escalate to the CMS: If the internal appeal fails, you can lodge a formal complaint with the Council for Medical Schemes. They have the power to override the scheme’s decision if they find the scheme is in breach of the Act.

Common PMB Myths Debunked

• Myth: “My medical aid is exhausted, so I have no cover.” Reality: PMB cover never runs out. Even if your “savings” are zero, the scheme must continue to pay for PMB treatments from their risk pool.
• Myth: “PMBs only apply to expensive plans.” Reality: PMBs are a legal right for every member of every registered scheme in South Africa.
• Myth: “I have to pay a co-payment for my chronic meds.” Reality: If you use the DSP and the formulary medication, there should be zero co-payment.

Integrating PMBs into Your Financial Planning

Understanding PMBs allows you to make smarter financial decisions. For example, if you have a chronic condition on the CDL, you might be able to choose a more affordable “hospital plan” knowing that your chronic medication and specialist visits will still be covered by the PMB mandate. 

However, you must still budget for non-PMB costs like routine GP visits, dentistry, and optometry, which are often not covered by basic plans.

Conclusion

Prescribed Minimum Benefits are your most powerful tool as a medical aid member. They ensure that when life hits hard with a serious diagnosis or a sudden emergency, your health and your wallet are protected by the law. 

By understanding the rules around DSPs, formularies, and registration, you can navigate the complex world of medical aid with confidence, ensuring you get the full value of the cover you pay for every month.