As a premium paying medical aid member, it is crucial that you have a clear understanding of the way that prescribed minimum benefits (PMBs) work, as they are a secure way for you to get high-level treatment in and out of hospital cost without having to pay extra out of pocket.
PMBs are difficult to understand for both patients and doctors, and they come with many caveats and rules. Schemes have different ways of dealing with the benefits, and it is very common for patients to be shortchanged in their benefits. It is a serious matter – in fact, it is so serious that Carte Blanche even did a segment on it a while back!
We have put together what we think is the most comprehensive guide on PMBs in the country. We will be adding and enhancing it as necessary, and if you think we have left out something important, please email us at firstname.lastname@example.org or leave a comment on this article.
How can rehealth help you with PMBs?
✔ Our partner-brokers can help you identify whether a treatment falls under PMB criteria
✔ We can guide you on how to discuss this with your scheme
You can read the guide from start to finish, or just click on the sub-topic most relevant to you from the table of contents below.
What are PMBs?
The prescribed minimum benefits obligate all medical aid schemes to pay for the diagnosis, treatment and care of:
- any emergency medical condition;
- a limited set of 270 medical conditions (defined in the Diagnosis Treatment Pairs);
- and 27 chronic conditions (defined in the Chronic Disease List).
Schemes have to cover at least the prescribed “PMB level of care” for these conditions, without requiring co-payments or savings from you, even if the treatment is provided out-of-hospital. This applies to every medical aid plan, even hospital plans only.
Understanding PMBs is important because although you might expect your medical scheme to pay for all hospital costs for any condition, you might not be aware that the medical scheme also has to pay for out of hospital costs for various conditions.
Question: So what kind of cover does this include?
You can view the 270 conditions on our site, as well as the 27 CDL (chronic) conditions. And all emergency (life-threatening) conditions are covered. Most cancers are covered. More examples of what is covered:
- Chemotherapy for breast cancer, including biological drugs in some cases (usually very expensive!)
- Regular out-of-hospital visits with your pulmenologist, if you have asthma
- Visits with a psychologist for depression or post trauma
Question: I only have a hospital plan, how does this affect me?
PMBs do not differentiate between what type of plan you have. They apply equally whether you have a hospital plan only, or are on a premium comprehensive plan. So, although of course a medical aid can offer more/higher benefit on the premium plans, no scheme can offer less than the required coverage just because you are on a “entry level” plan.
Question: I have medical insurance only. Do PMBs apply to me?
No. The PMBs are a feature as defined in the Medical Schemes Act, and only fall under medical aid schemes. Medical insurance companies are not obligated to offer PMB cover, and none do. This is a main difference between medical aid and medial insurance.