PMBs: everything you need to know

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Table of Contents

What are PMBs?

PMBs are Prescribed Minimum Benefits, as defined by the Medical Schemes Act. When you see a reference to a PMB on this site or in marketing brochures for medical aids, the term refers to the 270+ predefined PMB conditions. You can see a full list here.

Examples:
Asthma is a PMB condition. Your medical aid must pay for the diagnosis of your asthma, as well as for the ongoing treatment. This treatment includes out-of-hospital visits with a specialist, various tests and your monthly pump. If you follow your medical aid guidelines, you will not be required to pay out of pocket for any of this.

Your medical aid has to pay for the diagnosis, treatment and management of any of these 270+ conditions, regardless of which plan you are on.

The claim for a PMB has to be paid for by the medical aid, not from your savings.

Medical aids can impose a network of specialists and other designated service providers (DSPs), and if you do not use these providers you might have a co-payment. However, if you do use the providers, there can be no out-of-pocket payment if you follow the guidelines.

This is the list of the PMB conditions, including the 27 chronic conditions.

Who is covered?

Everyone who is on a medical aid has this benefit.

The only time you might not be entitled to a PMB benefit is if you are on a specific waiting period.

Note that only medical aid members are entitled to this benefit. Members of a medial insurance are not entitled to PMBs.

What is covered?

The diagnosis, treatment and management of your condition is fully covered. This includes tests, mediciation, specialist consults in and out of hospital, and hospital admissions.

You can see the exact prescribed benefits due for each condition here.

We also have some other useful articles to read:

Check your claims!

Medical aids are notorious for not paying out PMB claims correctly, usually due to administrative errors. It is very important that you stay on top of all claims to ensure that you are not overcharged.

You must follow your medical aids procedures for claiming for a PMB benefit. These are outlined in the scheme rules, in the marketing brochures or on the website. If the condition is chronic (eg asthma) you will need to register as a chronic patient for that condition. If the condition is not chronic, you must make sure that the doctor uses the correct codes to claim from the medical aid, otherwise you might not get the full benefit due to you.

We’ve written in much more detail much more detail about how medical aids should pay for PMBs, here.

Can my medial aid force me to use a State facility for a PMB?

Yes.

Your medical aid can limit the PMB benefits from certain providers only. Generally, only some the entry-level plans insist you use State facilities, and this is usually noted on our benefit pages. Even if you use a non DSP, the medical aid has to pay at least a portion of the PMBclaim. We explain this here.

My medical aid won’t pay for my PMB. What do I do?

Usually, it is because they are not aware that your claim falls under a PMB benefit. That is most often due to the wrong codes being used for the claim. Discuss this with your doctor.

If the codes are correct, the medical aid might need “a push” in the right direction. Tell them that your claim is a PMB, and that it needs to be paid by the scheme. Do this in writing.

There’s more help here:

Hi! I'm Eve Dmochowska, rehealth's founder.

Thanks for reading this far! I hope it was useful.

rehealth is a small, self-funded startup, growing the mission to help South Africans make informed healthcare choices. An informed patient is a healthier patient!

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