Prescribed Minimum Benefits (PMB’s): Questions & answers

(This information was directly taken from the Council for Medical Schemes little booklet: KNOW YOUR RIGHTS – The consumer’s guide on Prescribed Minimum Benefits (PMB’s) and Chronic Medication.)

Prescribed Minimum Benefits (PMB's) is 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. PMB's 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;
  • and 25 chronic conditions defined in the Chronic Disease List.
Medical Schemes must pay in full, without a co-payment or the use of deductibles for the diagnosis, treatment and care costs of the Prescribed Minimum Benefits (PMB's) conditions. The Medical Scheme cannot use your medical savings account or day to day benefit to pay for Prescribed Minimum Benefits 9PMB's). Each option offered by a medical scheme must make provision for the Prescribed Minimum Benefits (PMB's) including Hospital plan options.
Yes, the list of PMB's includes 25 common chronic diseases in the Chronic Disease List (CDL) and other chronic conditions within the +/-270 Diagnosis Treatment Pair (DTP) section. Medical schemes have to provide cover for the diagnosis, treatment and care of these diseases. However, you should remember that a medical scheme does not have to pay for diagnostic tests that establish that you are not suffering from a PMB condition. The treatment algorithms (guidelines for appropriate treatment) for each of the CDL chronic conditions have been published in the Government Gazette while the chronic diseases in the DTP section are guided by the public sector protocols. This assures you of good quality treatment and reassures your medical scheme that it will not have to pay for unnecessary treatment. Your doctor should know and understand most of the guidelines so that he or she can help you get the treatment you need for any of these conditions without incurring costs that our scheme does not cover.
The Council for Medical Schemes has been advising medical schemes to enter into contracts with any DSP they choose, especially State hospitals, to ensure that these providers can supply the necessary services. Other schemes have made arrangements with private hospital and certain retail pharmacies to treat their beneficiaries.
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Yes, medical schemes can make a benefit condition on you obtaining pre-authorization or joining a benefit management program. These programs are aimed at educating members about the nature of their disease and equipping them to manage it in a way that keeps them as healthy as possible. For example, many schemes offer treatment through groups that manage diseases such as diabetes, and are equipped to give the medication and monitor that disease.
Yes. The minimum medicines for treatment of all PMB conditions have been published in the Government Gazette, and are known as treatment algorithms (benchmarks for treatment). Your scheme may decide for which medicines it will pay for each chronic condition, but the treatment may not be below the standards published in the treatment protocols. Your medical scheme must, however, pay for the treatment if your doctor can prove that the standard medication is ineffective or detrimental to your condition.
Yes, the medical scheme may refuse to cover a part of the expenses. Your scheme may draw up what is known as a formulary a list of safe and effective medicines that can be prescribed to treat certain conditions. The scheme may state in its rules that it will only cover your medication in full if your doctor prescribes a drug on that formulary. Generally speaking, schemes expect their members to stick to the formulary medication. If you suffer from specific side-effects from drugs on the formulary, or if substituting a drug on the formulary with one you are currently taking affects your health detrimentally, you can put your case to your medical scheme and ask the scheme to pay for your medicine. If your treating doctor can provide the necessary proof and the scheme agrees that you suffer from side-effects, or that the drug is ineffective, then the scheme must give you an alternative and pay for it in full.
No, the regulations state that schemes cannot use your medical savings account to pay for PMB's.
No, your scheme cannot charge you a co-payment or levy on a PMB if you follow the scheme formulary and protocol. However, if your scheme appoints a Designated Service Provider (DSP) and you voluntary use a different provider, your scheme may charge you  the difference between the actual cost and what it would have paid if you had used the DSP or the percentage co-payment as registered in the scheme rules.
Yes, your scheme can set a limit for your chronic medicine benefit. Any chronic medication you claim for will then reduce that limit, regardless of whether or not it is one of the PMB chronic conditions. However, if you exhaust your chronic medicine limit, your scheme will have to continue paying for any chronic medication you obtain from its DSP for a PMB condition.
An emergency medical condition means the sudden and, at the time, unexpected onset of a health condition that requires immediate medical treatment and/or an operation. If the treatment is not available, the emergency could result in weakened bodily functions, serious and lasting damage to organs, limbs or other body parts, or even death. In an emergency it is not always possible to diagnose the condition before admitting the patient for treatment. However, if doctors suspect that the patient suffers from a condition that is covered by PMB's, the medical scheme has to approve treatment. Schemes may request that the diagnosis be confirmed with supporting evidence within a reasonable period of time.
Yes, all options regardless of contribution levels must cover PMB's at all cost in and out of hospital, including the 25 Chronic Conditions.
Contact details for Council of Medical Schemes.

Physical Address:
Hadefields, Block E
1267 Pretorius Street

Postal Address:
Private Bag X34

012-431 0500
0861 123 267 (CMS)

012-431 0560 / 012-430 7644