What are Prescribed Minimum Benefits (PMB)?

Prescribed Minimum Benefits (PMB) is a set of defined benefits to ensure that all medical scheme members (including dependants) have access to certain minimum health services, regardless of the medical scheme they belong to and the benefit option they have selected.

PMBs are included in the Medical Schemes Act and outlines the terms of which medical schemes have to cover the costs related to the diagnosis, treatment and care of the following:

emergency medical conditions
a set of 270 medical conditions (click here for list)
26 chronic conditions (click here for list)
When a doctor needs to decide whether a condition is a PMB, the only thing to look at are the symptoms of the condition and not at any other factors, such as how the injury or condition was contracted. Once the diagnosis has been made, the appropriate treatment and care is decided upon as well as where the patient should receive the treatment (at a hospital, as an outpatient or at a doctor’s rooms).

What to keep in mind when going for a planned PMB procedure in theatre in Hospital?

It is very important to take note of the following:

When going for a planned procedure and it is confirmed as a PMB, it is very important to know how your scheme covers planned PMB’s. This means that you need to confirm if you have to make use of specific designated service providers (Hospitals, Specialists etc.) or can you make use of any provider.

If you have to make use of specific designated service providers and you prefer not to (out of choice), the scheme will only pay the normal medical scheme tariff / rate for the procedure according to their scheme rules.

You will then have to pay the balance from your pocket or claim it from your GapCover. This however can become a problem, because not all GapCover products cover PMB’s.

What does it mean if a benefit on my option is covered according / subject to PMB?

This means that the scheme will cover the benefit / procedure equivalent to the treatment you will receive in a State facility.

An example of this would be the following: You need to undergo a knee replacement and the knee prosthesis the specialist will be using costs R30 000. Your benefit for knee replacements on your medical scheme benefit option states that it is covered according to PMB protocols. A knee prosthesis used in a State facility costs R15 000 (for example), which means that the balance of R15 000 will be for your own pocket.