27 Chronic Disease Conditions

What Medical Schemes Must Cover

The Chronic Disease List (CDL) is a set of 27 long-term medical conditions that all registered medical schemes in South Africa are required to cover. These conditions fall under the country’s Prescribed Minimum Benefits (PMBs), which means medical schemes must pay for the diagnosis, treatment, and ongoing management of these illnesses according to specific regulations.

The purpose of the CDL is to ensure that people living with chronic illnesses receive consistent medical treatment without interruption. Managing chronic diseases properly helps prevent serious complications and improves long-term health outcomes for members.

What Is the Chronic Disease List (CDL)?

The Chronic Disease List is part of South Africa’s healthcare legislation and is regulated by the Council for Medical Schemes. Medical schemes are required to provide benefits for these conditions even on basic hospital plans, provided that the diagnosis and treatment meet clinical guidelines.

CDL benefits typically include:

• Doctor consultations related to the chronic condition
• Approved chronic medication
• Monitoring tests and follow-up appointments
• Specialist referrals where necessary

However, members are usually required to register their condition with the medical scheme in order to receive these benefits.

The 27 Chronic Conditions Covered

The following conditions are included in the official Chronic Disease List:

• Addison’s disease
• Asthma
• Bipolar mood disorder
• Bronchiectasis
• Cardiac failure
• Cardiomyopathy
• Chronic obstructive pulmonary disease (COPD)
• Chronic renal disease
• Coronary artery disease
• Crohn’s disease
• Diabetes insipidus
• Diabetes mellitus type 1 and type 2
• Dysrhythmias
• Epilepsy
• Glaucoma
• Haemophilia
• Hyperlipidaemia
• Hypertension
• Hypothyroidism
• Multiple sclerosis
• Parkinson’s disease
• Rheumatoid arthritis
• Schizophrenia
• Systemic lupus erythematosus
• Ulcerative colitis

These conditions require ongoing treatment and monitoring, which is why they are protected under the medical scheme regulations.

How CDL Benefits Work

To access chronic disease benefits, members usually need to complete a registration process with their medical scheme. This process confirms the diagnosis and allows the scheme to approve medication and treatment plans.

Once approved, members typically receive their medication through designated pharmacies or approved service providers. Medical schemes often require the use of specific medicines listed on their formularies to control costs.

If a member chooses medication outside the scheme’s approved formulary, a co-payment may apply unless the alternative medicine is clinically necessary.

Designated Service Providers (DSPs)

Medical schemes may require members to use Designated Service Providers (DSPs) for the treatment of chronic conditions. These are doctors, pharmacies, or hospitals that have agreements with the scheme to provide treatment at negotiated rates.

If a member voluntarily chooses a provider outside the DSP network, the scheme may charge a co-payment.

Why the Chronic Disease List Is Important

The Chronic Disease List plays a critical role in protecting people living with long-term medical conditions. Without this regulation, many patients could struggle to afford essential medication and ongoing medical care.

By ensuring that these conditions are covered across all medical schemes, the CDL improves access to treatment and helps members maintain a better quality of life.

Frequently Asked Questions (FAQ)

What is the Chronic Disease List (CDL)?

The Chronic Disease List is a group of 27 chronic illnesses that South African medical schemes must cover as part of Prescribed Minimum Benefits.

Do all medical schemes cover the CDL conditions?

Yes. All registered medical schemes in South Africa must provide cover for CDL conditions according to the regulations set by the Medical Schemes Act.

Do I need to register my chronic condition with my medical scheme?

Yes. Members must usually register their condition with the medical scheme before chronic medication and treatment benefits are activated.

Will my chronic medication always be fully covered?

Medication listed on the scheme’s approved formulary is usually covered in full. If you choose alternative medication, a co-payment may apply.

Are CDL benefits available on hospital plans?

Yes. Even basic hospital plans must cover CDL conditions because they fall under Prescribed Minimum Benefits.