In terms of the Regulations to the Medical Schemes Act (Act no 131 of 1998), all medical schemes are required to cover a defined set of conditions known as Prescribed Minimum Benefit (PMB) conditions.
The Council for Medical Schemes defines PMBs as:
“…. a set of defined benefits to ensure that all medical scheme members have access to certain minimum health services, regardless of the benefit option they have selected. The aim is to provide people with continuous care to improve their health and well-being and to make healthcare more affordable. 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 270 Medical Conditions (defined in the Diagnosis Treatment Pairs or DTP); and 25 chronic conditions (defined in the Chronic Disease List or CDL).”
By ensuring this cover, the introduction of PMBs aims to:
- Provide treatment access, even where members do not have medical scheme cover due to their plan benefits or limits having been exceeded/depleted.
- Avoid excess pressure on the limited resources of public hospitals, as the state would have to manage these patients.
- Encourage more efficient use of the limited healthcare resources of the public and private sectors.
The PMB cover offered by the medical scheme should be managed under an insured benefit pool and must be covered, even if:
- there are specified medical scheme exclusions; and/or
- waiting periods apply; and/or
- a limit for a specific benefit has been depleted.
In order to contain costs of PMBs, medical schemes may assign designated service providers and apply managed care protocols to ensure a cost effective and efficient healthcare service to their members.
Note: For a more detailed explanation on PMBs, including objectives, conditions affected as well as FAQs, please visit the Council for Medical Schemes’ official website: