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Thinking about medical aid is enough to give anyone a headache. The jargon, T&Cs and the dreaded co-payments. One term that all medical aids undoubtedly use is Prescribed Minimum Benefits (PMBs), but it is another grey area that many people are not too clued up on.

What are PMBs?

PMBs are a set of defined benefits as prescribed by the Medical Schemes Act, in terms of which medical schemes, irrespective of benefit option, have to cover the costs related to the diagnosis, treatment and care of:

• any emergency medical condition
• a limited set of 271 medical conditions (defined in the Diagnosis Treatment Pairs)
• 25 chronic conditions (defined in the Chronic Disease List)

Chronic illnesses are defined broadly as conditions that last one year or more and require ongoing medical attention or limited daily activities or both.

Why do we have PMBs?

There are two main reasons why PMBs were created:

1. To ensure that medical scheme beneficiaries have continuous healthcare. This means that even if a member’s benefits for a year have run out, the medical scheme has to pay for the treatment of PMB conditions.
2. To ensure that healthcare is paid for by the correct parties. Medical scheme beneficiaries with PMB conditions are entitled to the specified treatments and these have to be covered by their medical scheme, even if the patients were treated at a state hospital.

Other valid reasons include:

3. Ensuring that minimum healthcare is provided equitably to all who need it, regardless of their age, state of health or the medical scheme cover option they belong to.
4. PMBs also have a part to play in ensuring that medical schemes remain financially healthy. When beneficiaries receive good and proper care on an ongoing basis, their general wellness improves, resulting in fewer serious conditions that are expensive to treat.

How does a doctor decide if my condition will be covered by a PMB?

Your doctor will assess your symptoms to decide whether your condition can be covered as a PMB. In other words, they will not look at how the condition was contracted in the first place, but rather the symptoms you are displaying at that current point in time. Once diagnosis is made, they will then decide where you should receive the treatment in terms of in the doctor’s rooms or in hospital.

What kind of conditions does a PMB cover?

Your medical scheme can provide you with the full list of PMB conditions, also available on the Council for Medical Schemes’ (CMS’) website, which are grouped into 15 broad categories and include conditions such as heart attacks, strokes and pneumonia. The 25 chronic diseases in the PMBs list include conditions such as epilepsy and bipolar mood disorder.

Minimum provision for PMBs as per the public sector will apply.

The treatment and care should be based on healthcare that has proven to work best, taking affordability into consideration.

How do I access my PMB benefits?

1. Your condition must be on the list of defined PMB conditions

Once your treating healthcare provider has provided you with your results, you must provide your scheme with the diagnosis. If applicable, the scheme will then register you on the relevant scheme’s disease management programme.

2. Your treatment must match those in the defined benefits on the PMB list

There are standard treatments, referred to as algorithms, procedures, investigations and consultations for each PMB condition on the list outlined by the Medical Schemes Act. These defined benefits are supported by thoroughly researched and evidence-based treatment guidelines.

3. You must use the scheme’s Designated Service Providers (DSPs) for full cover

A DSP is a healthcare provider (e.g. doctor, specialist, pharmacist, or hospital) who has an agreement with your scheme to provide treatment or services at a contracted or negotiated rate. The services of these providers must be used to get full cover for PMB treatment and care.

It is important to make use of healthcare providers that are in your scheme’s DSP. This ensures that you will not incur any co-payments for your treatment. While your scheme will always try to ensure that a DSP is available in your area, in a case where you are not able to find a DSP, your scheme will be able to cater to you outside of the network. In this case, however, you will need to provide proof to the scheme.

In an emergency, you can go directly to hospital and notify the scheme of your admission as soon as possible. In the case of an emergency, you are covered in full for the first 24 hours or until you are stable enough to be transferred to a DSP. Remember, benefits not included in the PMBs are paid for from your available plan benefits, where appropriate, and according to the rules of your chosen health plan. Supporting documentation confirming the PMB condition (e.g. the radiology report, pathology report, motivation) may be required to review benefits.

4. The treating provider must apply by completing a PMB application form and attach supporting clinical documents (reports/letter of motivation etc.) and send it to: 

Email: pmb@bestmed.co.za

Fax: 012 472 6760

Exclusions and PMBs

Medical schemes are entitled to exclude specific services/events e.g. cosmetic surgery, travel costs and examinations for insurance purposes etc.

In some circumstances, exclusions may not apply to PMBs, e.g. when a patient gets septicaemia after cosmetic surgery. The Scheme has to provide certain cover for septicaemia since septicaemia is a PMB. However, cosmetic surgery remains an exclusion.

Is COVID-19 a PMB?

Effective 7 May 2020 the Regulations to the Medical Schemes Act was amended to make provision for PMB level of care for COVID-19. Screening, testing and treatment of COVID-19 is considered a PMB and will be funded in accordance with the scheme treatment guidelines and baskets of care, and designated service providers where applicable.

Remember, PMBs are prescribed both for your benefit and that of your scheme. If there is anything that you do not understand, you are always encouraged to engage with your scheme so that you are able to maximise your benefits and minimise the chances of additional payments that you may be required to cover.