Understanding Prescribed Minimum Benefits (PMBs)
What are PMBs?
Prescribed Minimum Benefits (PMBs) are a set of defined benefits that all registered medical schemes in South Africa are obliged to provide for all their members. All members have access to these benefits, irrespective of their chosen benefit option. PMBs ensure that all medical scheme members have access to continuous care to improve their health.
PMBs are governed by law
PMBs are guided by a list of medical conditions as defined in the Medical Schemes Act 131 of 1998.
According to the Medical Schemes Act 131 of 1998 and its Regulations, all medical schemes must cover the costs related to the diagnosis, treatment, and care of:
- Any life-threatening emergency medical condition
- A defined set of 271 diagnostic treatment pairs
- 27 chronic conditions
|
PMB category |
Description |
|
Emergency Medical Conditions |
An emergency medical condition, also referred to as an emergency, is the sudden and, at the time, unexpected onset of a health condition that requires immediate medical and surgical treatment, where failure to provide medical or surgical treatment would result in serious impairment to bodily functions or serious dysfunction of a bodily organ or part or would place the person's life in serious jeopardy. An emergency does not necessarily require a hospital admission. We may ask you for additional information to confirm the emergency. |
|
Diagnostic Treatment Pairs (DTP) |
271 condition-treatment pairings, based on diagnosis and evidence-based care |
|
Chronic Disease List (CDL) |
27 chronic conditions that require long-term management |
The treatment of CDL conditions is covered, subject to using approved medications and registering with the Scheme.
For a full list of DTPs and CDLs, visit the Council for Medical Schemes website.
Who qualifies for PMBs?
There are certain requirements before you can benefit from PMBs. The requirements are:
- The condition must qualify for cover and be on the list of defined PMB conditions; and
- The treatment needed must match the treatments in the defined benefits on the PMB list
PMB regulations and their accompanying provisions do not apply to healthcare services obtained outside the borders of South Africa.
PMB related claims for services obtained outside the borders of South Africa will be treated in accordance with your chosen network option, subject to the relevant Scheme Tariff and any other limitations applicable to your benefits within the borders of South Africa.
How we pay for In-Hospital PMBs
We pay for confirmed PMBs in full up to the negotiated rate for providers we have agreements with, i.e. for pathology Sasolmed has payment agreements with Ampath, Lancet, Pathcare and Vermaak and Partners.
Where we do not have agreements in place, we will pay at cost.
We may require additional supporting documents to confirm cover as a PMB. Documents may be requested confirming your diagnosis, for example Magnetic Resonance Imaging (MRI) scans, pathology, and endoscopic procedure reports.
We pay for benefits not included in the PMBs from your appropriate and available hospital benefit and/or your out of hospital benefits, according to the Rules of your chosen network option.
Find healthcare providers
You can access the Find a healthcare provider tool on our website to find a healthcare provider near you.
In-Hospital Pre-Authorisation:
- Contact us on 0860 002 134 to get pre-authorisation.
- We will give you an authorisation number.
- Please give the authorisation number to the relevant healthcare provider and ask them to include this when they submit their claims. Please make sure you understand what is included in your authorisation and how we will pay your claims
Out-of-hospital Authorisation:
- Complete an application form
- Available on our website under Find a document > Guides and Applications
Important: Use a Preferred General Practitioner (PGP) from the DSP network. Not doing so may lead to out-of-pocket payments.
What happens in an emergency?
In an emergency you must go directly to a hospital and notify the Scheme within 48 hours of your admission.
How to access Out-of-Hospital PMB benefits
You and your dependants must register for PMB cover. Types of cover include:
- Chronic Disease List (CDL) conditions
- Out-of-hospital management of PMBs
- HIV
- Oncology
Why registration matters
Once registered, your care is covered under PMBs. This includes consultations, medication, blood tests, and more. These services are not deducted from your day-to-day benefits.
If you use treatments or medication not on the defined PMB list or approved, the cost is covered from your available benefits, based on your chosen network option.
Learn more
Learn more about PMBs for:
Tips
Always check if your treatment requires use of a DSP to avoid co-payments.
Keep your PMB registration updated.
Use the tools on the Sasolmed website to stay informed.