If you are a member of a medical scheme in South Africa, you and your listed dependants are entitled to a set of benefits known as prescribed minimum benefits (PMBs), no matter which plan, or option, you are on.
PMBs were introduced by the Council for Medical Schemes (CMS) in 2000, guaranteeing a minimum level of cover by schemes. They ensure you have access to essential healthcare services for serious conditions without the fear that you won’t be covered.
A spokesperson from Medshield medical scheme elaborates: “PMBs are a set list of conditions that all medical schemes are required by law to cover under the Medical Schemes Act. PMBs aim to ensure that medical scheme beneficiaries receive continuous cover for life-threatening diseases or events. This means that even if a member’s annual benefits are exhausted, the medical scheme must cover the PMB condition’s treatment, provided the condition meets the specific requirements of the Medical Schemes Act.”
Conditions covered
PMBs cover the diagnosis, treatment and management of 271 mostly life-threatening conditions, 26 common chronic conditions, and medical emergencies, such as life-threatening injuries sustained in an accident. The list of conditions is available on the CMS website.
Some of the more well-known conditions listed are: meningitis; stroke; cataracts; most cancers; Covid-19 (including testing if referred by a doctor, even if negative, and vaccination); pneumonia; heart disease; appendicitis; gastric ulcers and hernias; gastroenteritis (if life-threatening); bone fractures; iron or vitamin deficiencies (if life-threatening); drug or alcohol dependence; anorexia and bulimia; and dementia caused by, among other things, Parkinson’s disease but not, strangely, Alzheimer’s disease.
Chronic conditions include diabetes (Types 1 and 2); glaucoma; epilepsy; hyperlipidaemia (high cholesterol); hypertension (high blood pressure); rheumatoid arthritis; lupus; and ulcerative colitis.
Your medical scheme cannot use your medical savings account to cover PMBs; it must pay for the treatment from your risk benefit.
Some schemes may not be open and transparent about what you are entitled to. For instance, if you have one of the 26 listed chronic conditions, your scheme must cover all treatment related to that condition – not just your medication, but related doctor consultations and tests.
PMBs are identified by universal codes for medical conditions, known as ICD10 codes. On your doctor’s bill the treatments will be according to these codes. If the bill is submitted to the medical scheme with an ICD10 code for a PMB condition, the scheme is obliged to cover it as a PMB. For example, a Covid-19 PCR test referred to by a doctor will have the code U07.2. The scheme should pick this up when processing the claim and pay for it from your risk benefit.
Designated providers
In a major concession to schemes when it instituted PMBs, the CMS said schemes could appoint designated service providers (DSPs) for the treatment of PMB conditions. Schemes will pay for this treatment in full, but if you use a different provider, you may have to pay the difference from your own pocket.
However, the CMS stipulates that it must be convenient for you to use the scheme’s DSP. In its pamphlet “10 things no one tells you about PMBs”, the CMS notes: “Your medical scheme has to ensure that it is easy for you to get to the DSP. If there is no DSP reasonably close to your work or home, then you can visit any provider and the scheme has to pay.”
Using a DSP is not required in a medical emergency, if, say, you are involved in an accident. “You may go to the nearest healthcare facility for treatment, even if it is not a DSP,” the CMS says.
Management of PMBs
Schemes have established management programmes to treat some of the more common PMB conditions, such as diabetes, using their DSPs. They also provide a list of medicines that the scheme will pay for in full. This means that if you don’t follow the procedure set out by your scheme – if you do not get pre-authorisation from the scheme and use different service providers and different medicines – you will likely have to pay a hefty portion of the bill from your own pocket.
Says the Medshield spokesperson: “Although there is this guaranteed coverage, you must be aware of the specific requirements outlined in your benefit option and medical scheme rules. Ask questions and follow the complaints process if you feel you are not treated fairly. By demystifying PMBs and understanding their significance, you can confidently take charge of your health care.”
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