Prescribed Minimum Benefits
Prescribed Minimum Benefits (PMBs) are guided by a list of medical conditions as defined in the Medical Schemes Act of 1998. According to the Medical Schemes Act 131 of 1998. and its regulations, all medical schemes have to cover the costs related to the diagnosis, treatment and care of:
- Any life-threatening emergency medical condition
- A defined set of 271 diagnoses
- 26 chronic conditions (Chronic Disease List conditions).
There are standard treatments, procedures, investigations and consultations for each PMB condition on the 271 diagnostic treatment (DT) PMB list. These defined benefits are supported by thoroughly researched, evidence based clinical protocols, medicine lists (formularies) and treatment guidelines.
Please refer to the Council for Medical Schemes website, www.medicalschemes.co.za, for a full list of the 271 diagnostic treatment conditions.
The Scheme pays for confirmed PMBs in full if you receive treatment from a Designated Service Provider (DSP). Treatment received from a healthcare provider that is not a DSP may be subject to a co-payment and the shortfall will be for your own pocket if the healthcare provider charges more than the Scheme Tariff.
There are different types of PMBs: PMB cover for in-hospital admissions, conditions covered under the Chronic Disease List, the out-of-hospital management of PMB conditions, and treatment of specific PMB conditions, such as HIV or oncology.
The person with the PMB or chronic condition must complete the relevant application form with the help of their treating healthcare provider.
Each person with a PMB or chronic condition must register their specific conditions separately. You only have to register once for a chronic condition. If your medicine or other treatment changes, your healthcare provider can let us know about these changes.
For new PMB conditions, you will have to register each new condition before we will cover the treatment and consultations from the Prescribed Minimum Benefits, not from your day-to-day benefits.
Documents for your Prescribed Minimum Benefit cover:
Guide to Prescribed Minimum Benefits for In-hospital treatment
Guide to Prescribed minimum Benefits for out-of-hospital treatment