According to the Medical Schemes Council, PMBs 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 (defined in the Diagnosis Treatment Pairs);
- and 25 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 plan.
PMBs and cancer
Some plans provide cancer treatment for “PMB cases only”. Most cancers are considered PMBs, and therefore you are funded for out-of-hospital treatment for cancer under the PMB legislation, even if you are on a hospital-only plan.
However, there are some restrictions. For starters, only treatable cancers are considered PMBs. Once again, according to the government notes:
In general, solid organ malignant tumours (excluding lymphomas) will be regarded as treatable where:
i) they involve only the organ of origin, and have not spread to adjacent organs
ii) there is no evidence of distant metastatic spread
iii) they have not, by means of compression, infarction, or other means, brought about irreversible and irreparable damage to the organ within which they originated (for example brain stem compression caused by a cerebral tumour) or another vital organ
iv) or, if points i. to iii. do not apply, there is a well demonstrated five year survival rate of greater than 10% for the given therapy for the condition concerned
If your scheme covers only PMB cancer and your cancer does not meet the above criteria, it will not be covered.
You can change plans within the same scheme and not have new waiting conditions applied. Some schemes allow you to upgrade immediately to a higher plan if you are diagnosed with a life-changing condition. Other schemes only allow the change on January 1. Speak to your broker.)