Understanding Prescribed Minimum Benefits

Prescribed Minimum Benefits (PMBs) is a set of defined benefits that ensures that all medical scheme members have access to certain minimum health services, no matter what benefits option they have selected. The purpose of PMBs is to provide support and care to the public, make healthcare more affordable and motivate members to better their health and well-being.

As a member of a South African medical aid scheme, you have access to cover for the 26 Prescribed Minimum Benefits (PMB) and 25 Chronic Disease List (CDL) conditions. According to the Council for Medical Schemes (CMS), PMBs are a feature of the Medical Schemes Act, in terms of which medical schemes have to cover the costs related to the diagnosis, treatment, and care of:

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

To better understand PMBs, your medical cover, and if you are entitled to claim, you should consult your healthcare broker. You could not only be missing out on urgent care that you require, but you could also prevent unnecessary expenditure. If you have one of the 25 listed chronic conditions, your medical scheme not only has to cover the medication for that condition but also cover doctor consultations and prescribed tests related to that condition.

While medical schemes must cover PMBs in full as regulated by the Council of Medical Schemes, some schemes have implemented measurements and criteria to safeguard the scheme’s risk against fraudulent claims. Speak to your Glopin Healthcare Consultant to ensure you understand the process of how to apply and claim for PMBs to prevent your PMB claim from being denied.

Some of the factors to note with regards to PMBs include:

  • PMB claims are not always automatically processed. PMB cover must be applied for together with your broker and healthcare practitioner.
  • Some schemes limit the use of medication from a prescribed medicine list.
  • Many schemes have designated service providers and hospital networks in place for treating and managing PMBs

Speak to your Glopin Healthcare Consultant to ensure treatment, chronic condition medication, or tests fall within the scope of PMBs and save money while improving your health and wellness.