What is a Prescribed Minimum Benefit (PMB)?
Prescribed Minimum Benefits are prescribed by law as a minimum benefit package that each medical scheme member is entitled to. The Council for Medical Scheme's regulations state that medical schemes need to provide cover for certain conditions at designated service providers; even when scheme exclusions, or certain waiting periods apply, or when the member has reached their limit for a benefit. A designated service provider is a healthcare provider (for example doctor, specialist, pharmacist or hospital) who we have an agreement with, to provide treatment or services at a contracted rate.
PMBs are guided by a list of medical conditions as defined in the Medical Schemes Act. According to this, all medical schemes have to cover diagnosis, treatment and care costs related to:
- An emergency medical condition
- A defined set of 271 diagnoses
- 26 chronic conditions (Chronic Disease List conditions).
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. You must also register on the Scheme's disease management programmes to qualify for PMB cover. For more information on where to send completed application forms see the Guide to PMBs. - 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 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 the case of 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 plan benefits, where appropriate and according to the rules of your health plan.
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You and your dependants must register to get cover for PMBs
How do I register a Prescribed Minimum Benefit condition?
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 a Prescribed Minimum Benefit or a Chronic Illness Benefit application form.
- Up to date forms are always available on our website here under Application forms.
- For more information on the PMB Chronic Disease List conditions, HIV or Oncology and how to register, visit our website here and search under Benefit guides.
- To confirm your in-hospital cover for PMB conditions, you can call us on 0860 100 421 and request an authorisation. We will then tell you about your cover.
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 for 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-today benefits.