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Understanding prescribed minimum benefits
Navigating medical aid benefits can feel overwhelming, especially when you aren’t sure which treatments or conditions your scheme is legally required to cover. One area that often causes confusion is Prescribed Minimum Benefits, commonly known as PMBs. These benefits are an important part of medical aid cover, but they’re not always easy to understand.
PMBs play an important role in ensuring medical aid members have access to certain minimum healthcare benefits, regardless of the medical aid plan selected.
Knowing how PMBs work can help people make more informed healthcare decisions and better understand their rights as medical aid members.
What are Prescribed Minimum Benefits (PMBs)?
PMBs, are a set of minimum healthcare benefits that all registered medical aid schemes in South Africa are legally required to provide.
The Medical Schemes Act requires all registered medical aid schemes to provide these benefits, helping members access treatment for certain serious conditions and medical emergencies.
What conditions do PMBs cover?
The PMB package covers emergency medical conditions, 271 listed Diagnosis and Treatment Pairs, and 26 chronic diseases on the Chronic Disease List, including conditions such as diabetes, asthma, epilepsy, hypertension and bipolar mood disorder.
Treatment generally has to meet the scheme’s clinical requirements and may need to be provided by designated service providers, depending on the rules of the scheme.
One of the most important components of PMB cover relates to emergency medical conditions.
What is an emergency medical condition?
An emergency medical condition refers to the sudden onset of a serious illness or injury requiring immediate medical treatment.
In these situations, delaying treatment could:
- Place a person’s health at serious risk
- Result in serious impairment of bodily functions
- Cause serious dysfunction of an organ or body part
Medical aid schemes are required to provide cover for the diagnosis, treatment and care associated with PMB-related emergency conditions, subject to the Medical Schemes Act and scheme rules.
Why members may still receive additional bills
Many people assume that PMBs mean every related medical account will automatically be paid in full. In practice, though, members may still face out-of-pocket costs in certain circumstances, particularly where the scheme’s rules, provider networks or treatment requirements haven’t been followed.
This can happen when:
- Treatment is received outside the scheme’s designated service provider network, where a Designated Service Provider was available and the member chose not to use it
- Required authorisation, treatment protocols or formularies aren’t followed
- A provider charges more than the amount funded by the scheme, and the claim isn’t covered in full under PMB rules
- Certain services, medicines or treatments fall outside the approved PMB level of care or funding criteria
In many cases, these costs can be reduced or avoided by understanding your scheme’s rules, approved provider networks, authorisation requirements and treatment protocols before receiving care, where possible. It’s also one reason many medical aid members consider additional healthcare cover, such as Gap Cover, to help manage eligible shortfalls that may not be fully covered by their medical scheme.
Where additional cover may assist
This is where Gap Cover may play a useful role. It’s designed to help with certain medical expense shortfalls that can arise when healthcare providers charge more than the amount covered by a medical scheme. It doesn’t replace medical aid, and it should not be seen as a substitute for understanding or enforcing PMB rights. Cover will always depend on the policy terms, limits and exclusions, but for eligible claims, it can provide an added layer of financial protection where approved in-hospital or specialist-related costs are not covered in full.
Get Gap Cover now!
