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Prescribed Minimum Benefits (PMBs)

Prescribed Minimum Benefits (PMBs) are a set of defined healthcare benefits that all registered medical aid schemes in South Africa are legally required to provide. These benefits ensure that members have access to essential healthcare services, regardless of the plan they choose.

PMBs were introduced to protect consumers from catastrophic medical expenses and to ensure that serious medical conditions receive adequate treatment. Whether you are on a hospital plan, savings plan, or comprehensive medical aid, PMB cover forms the foundation of your healthcare protection.

What Are Prescribed Minimum Benefits?

Prescribed Minimum Benefits are defined in the Medical Schemes Act and include:

Medical schemes must pay for the diagnosis, treatment, and care of these conditions in full, provided members follow scheme rules and use designated service providers where required.

What Conditions Are Covered Under PMBs?

PMBs include a wide range of serious health conditions such as:

  • Heart attacks and strokes
  • Cancer
  • Diabetes
  • Epilepsy
  • Asthma
  • Chronic kidney disease
  • Major trauma requiring emergency treatment

These conditions are covered to prevent financial hardship caused by life-threatening or long-term illnesses.

How PMB Cover Works

For PMBs to be paid in full, members usually need to:

  • Use the scheme’s designated service providers (DSPs)
  • Obtain pre-authorisation where required
  • Follow treatment protocols approved by the scheme

If you voluntarily use a non-network provider when a designated provider is available, you may be responsible for co-payments.

PMBs and Hospital Plans

Even the most basic hospital plan must provide full cover for PMB conditions. This means that if you are diagnosed with a listed PMB condition, your medical aid cannot refuse treatment or limit benefits unfairly.

However, cover is subject to clinical guidelines and scheme rules. Understanding your specific plan’s requirements is essential to avoid unexpected out-of-pocket costs.

Why Prescribed Minimum Benefits Matter

PMBs protect medical aid members from severe financial strain during medical emergencies or serious illnesses. Without these regulations, schemes could limit or exclude essential treatments.

PMBs also promote fairness and standardisation across all registered medical aid schemes, ensuring that every member receives a baseline level of protection.

Common Misunderstandings About PMBs

  • Myth: PMBs are only covered on comprehensive plans.
    Fact: All registered medical aid plans must provide PMB cover.
  • Myth: PMBs cover all medical expenses.
    Fact: PMBs cover specific listed conditions and treatments only.
  • Myth: You can use any doctor without consequence.
    Fact: Using non-network providers may result in co-payments.

Frequently Asked Questions

What are Prescribed Minimum Benefits (PMBs)?

PMBs are a set of essential healthcare benefits that all registered medical aid schemes in South Africa must provide by law.

Do all medical aid plans cover PMBs?

Yes. Every registered medical aid scheme must cover PMBs, regardless of whether you are on a hospital, savings, or comprehensive plan.

Are chronic conditions covered under PMBs?

Yes. There are 26 chronic conditions listed under the Chronic Disease List (CDL) that must be covered as part of PMBs.

Can I choose any hospital for PMB treatment?

Medical schemes may require you to use designated service providers. Using a non-network provider could result in co-payments.

Do PMBs cover emergencies?

Yes. All emergency medical conditions are included under Prescribed Minimum Benefits.

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