Welcome back to Cover to Cover: Medical Schemes Explained, a column in partnership with Medihelp aimed at helping financial advisers simplify medical schemes for their clients. Each edition addresses common questions, decodes industry terms, and provides insights to help clients make informed decisions.
Click here to read the first edition of Cover to Cover, which was on decoding medical scheme plans.
This edition focuses on the Prescribed Minimum Benefits (PMBs) – an essential part of every medical plan in South Africa.
What is a PMB, and which conditions qualify?
The PMBs are a set of benefits that, by law, every registered medical scheme must cover. Regulated under the Medical Schemes Act and enforced by the Council for Medical Schemes (CMS), the PMBs include:
- 271 medical conditions, covering most life-threatening emergencies, chronic conditions, and other severe illnesses.
- 26 chronic conditions listed on the Chronic Disease List (CDL).
- All emergency medical conditions where delaying care would risk life or long-term health.
Examples include diabetes, asthma, epilepsy, hypertension, cancer, HIV, heart attacks, and strokes. The full list of PMBs is published by the CMS.
Does every plan include PMBs?
Yes. By law, every registered medical scheme plan in South Africa must include PMB cover, whether it is a hospital-only, network, or comprehensive plan.
What differs across plans is how PMBs are funded. Some plans may require the use of designated service providers (DSPs), networks, or formulary medication (lists of approved medication).
But the benefits themselves do not differ – a scheme cannot exclude PMBs from a plan, but the basket of benefits may differ. This means that the baskets of care may be different, depending on formularies. Some plans will have richer benefits than others in terms of what medicine is available and with what co-payment.
How does PMB cover work in practice?
Schemes must pay in full for PMBs when you use a DSP and follow scheme protocols.
If a provider charges above the scheme rate:
- Using a DSP: the scheme pays in full, no out-of-pocket cost.
- Using a non-DSP without valid reason: you may have to pay the difference.
Valid reasons for using a non-DSP (full cover still applies) include:
- No DSP was available.
- Immediate emergency treatment was required.
- You were far from a DSP and could not reasonably access one.
For example, if a psychologist treating depression (a PMB condition) charges above the scheme’s set tariff and is not a DSP, you might need to cover the difference.
Network or hospital plans – must PMB providers be on the scheme’s list?
Yes. Schemes can require members to use network or contracted DSPs for PMBs.
If you voluntarily choose a provider outside the network, the scheme may limit payment to its set tariff, leaving you with a co-payment.
In emergencies or when no DSP is available, the scheme must still cover the full cost of PMB treatment.
Does PMB cover medication, and who pays?
Yes. When in line with the PMB, both the healthcare services and the medication needed to treat the PMB condition will be covered.
- Schemes may use a formulary of approved drugs.
- Using a formulary medication from a DSP pharmacy means the scheme must cover it in full.
- Choosing a non-formulary drug when a formulary alternative is clinically appropriate may require a co-payment.
Medical schemes are responsible for covering PMB medication, following protocols and funding guidelines that consider clinical evidence, cost-effectiveness, scheme and plan affordability, and DSP arrangements.
In summary:
- PMBs are mandatory across all medical scheme plans.
- They cover emergencies, 271 listed conditions, and 26 chronic diseases.
- Full cover applies when using DSPs and following formularies/protocols.
- Members may face co-payments if they choose non-DSP providers or non-formulary medication without clinical justification.
Understanding PMBs helps advisers to guide clients to make informed decisions about their medical plans and ensure access to essential healthcare when it matters most.
Next edition: We’ll unpack waiting periods – who is affected, how they are determined, typical durations, and how advisers can guide clients who are hesitant to join due to these restrictions.
It is of vital importance for Advisers & Members to be aware, that
* The Diagnosis (ICD10) as provided by the Treating Healthcare Provider, is the determining factor of whether a diagnosis, indeed qualifies as a PMB Condition & PBM Level of Care.
(Inaccurate/Inappropriate ICD10 codes, will result in incorrect claim processing & payments, respectively)
🔹 Involuntary Use of non-DSP
“You were far from a DSP and could not reasonably access one.”
❓ Has the CMS clarified the actual appropriate distance (km’s) , which would justify Non-DSP utilisation, due to unavailability of a Scheme DSP in close and/or reasonable proximity, from a member’s residence?
Interpretation of the the term “reasonable proximity” vary amongst schemes, with most – “accepting” a distance of between 30-50km radius from a member’s residence – in which a DSP is not available.