UNDERSTANDING PRESCRIBED MINIMUM BENEFITS (PMB's)

What are PMB's?

Prescribed Minimum Benefits (PMBs) are a set of defined benefits to ensure that all medical scheme members have access to certain minimum healthcare services, regardless of the benefit option they select. The aim is to provide people with continuous care, to improve their health and wellbeing and to make healthcare more affordable.
Prescribed Minimum Benefits are a feature of the Medical Schemes Act 131 of 1998, which states that medical schemes are required by law to cover the costs related to the diagnosis, treatment and care of:

Any emergency medical condition
A limited set of 270 medical conditions
27 chronic conditions (defined in the Chronic Disease List).

Please refer to the Council for Medical Schemes website www.medicalschemes.co.za for a full list of the 271 diagnostic treatment pairs. All medical schemes in South Africa have to include PMBs in the options they offer to their members.

What must happen for you to access PMB benefits?

There are certain requirements to meet before you can benefit from PMBs. These are:

Your condition must qualify for cover and be on the list of defined PMB conditions You should send the Scheme the results of your medical tests that confirm the diagnosis of your condition. This will allow us to identify that your condition qualifies for the treatment. Your doctor must provide the correct information, confirming the diagnosis.
Your treatment must match those in the defined benefits on the PMB list There are standard treatments, 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.
You must use the Scheme's Designated Service Providers (DSPs) for full cover If you do not use a DSP, we will pay up to 80% of the Medical Scheme Rate and you will be responsible for the difference between what we pay, and the actual cost of your treatment. This does not apply in emergencies though. In an emergency, you can go directly to hospital and notify the Scheme of your admission as soon as possible. In an emergency, you are covered in full for the first 24hrs 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 option benefits, where appropriate and according to the rules of your benefit option.

You and your dependants must register to get cover for PMBs

There are different types of PMB cover. These include cover for: in-hospital admissions, conditions under the Chronic Disease List, out-of-hospital management of PMB conditions, and treatment of PMB conditions, such as HIV or oncology.

To apply for out-of-hospital PMBs, or cover for a Chronic Disease List (CDL) condition, you must complete an application form.

Up to date forms are always available on our website under "Application Forms"
For more information on the PMB Chronic Disease List conditions, HIV or Oncology and how to register, visit the website and search under "Benefit Guides"
To confirm your in-hospital cover for PMB conditions, you must call us on 0860 100 078 and request an authorisation. We will then tell you about your cover. Whenever your doctor plans to take you to hospital, you must let us know at least 72 hours before you go to the hospital or day clinic.
Please note: If you don't preauthorise your admission, you will have to pay a R2 640 shortfall on the hospital account.

Why it's important to register your PMB

We pay for specific healthcare services related to each of your approved conditions. These services include approved treatment, medicine, consultations, blood tests and other defined tests. These are paid from your Prescribed Minimum Benefits and will not affect your day-to-day benefits.
We will pay for treatment or medicines that fall outside the defined benefits and that are not approved, but this is paid from your available day-to-day benefits.