Your complete guide to prescribed minimum benefits

Prescribed Minimum Benefits are the minimum level of healthcare benefits that medical schemes are required to provide. They are set in place to ensure that members are guaranteed access to a standard of healthcare services and cover a range of medical treatments and services for certain recognised conditions or medical events. Discover more about Prescribed Minimum Benefits as Bloom discusses this benefit in more detail. To find affordable health insurance quotes, you can get health insurance quotes tailored to your needs.

What are Prescribed Minimum Benefits and how does it work?

Prescribed Minimum Benefits, or PMBs, are a set of healthcare services that medical aid schemes are legally required to cover in South Africa. These benefits are set by the Medical Schemes Act of 1998, which mandates that all registered medical schemes must provide certain minimum benefits to their members. PMBs are designed to ensure that medical aid members have access to essential healthcare services, regardless of the medical aid scheme or plan they have selected.

Prescribed Minimum Benefits include diagnosis and treatment of certain medical conditions, which are classified as critical, chronic or life-threatening. As of September 2021, there are 270 recognised medical diagnoses; and 27 chronic diseases or conditions. However, it must also be noted that while PMBs provide essential cover, it does not cover all expenses related to the services. Depending on the member’s plan and limits, the member may still have to pay out-of-pocket for certain co-payment and deductibles.

All members of medical aid schemes that are registered in South Africa are eligible for PMBs, regardless of the medical aid plan they have chosen.

What medical conditions are covered by PMBs?

As per the Medical Schemes Act of 1998, all medical aid schemes are required to cover the costs related to the diagnosis, treatment and care of any life-threatening condition or emergency, a set of 270 medical diagnoses and 27 chronic diseases.

Some of the treatments covered under the set of defined medical diagnoses include:

  • Emergency medical services and care
  • Management of asthma
  • HIV/AIDS treatment and care
  • Tuberculosis treatment and care
  • Dialysis and kidney transplantation
  • Radiation and chemotherapy for cancer
  • Palliative care for patients with life-threatening diseases
  • Organ transplants and associated care
  • Prostheses and orthoses
  • Occupational therapy for people with disabilities or injuries
  • X-rays and diagnostic imaging for medical purposes

The 27 chronic diseases and conditions include the following:

  • Addison’s disease: a hormonal disorder where the adrenal glands don’t produce enough of certain hormones.
  • Asthma: a chronic respiratory disease characterised by inflammation and narrowing of the airways, causing breathing difficulties.
  • Bipolar mood disorder: a mental disorder characterised by episodes of manic and depressive mood swings.
  • Bronchiectasis: a lung condition where one’s airways are permanently, inflamed, making it difficult to breathe.
  • Cardiac failure: a heart condition where the heart is unable to pump blood properly.
  • Cardiomyopathy: a disease of the heart muscle that can cause heart failure.
  • Chronic obstructive pulmonary disease: a progressive lung disease making it difficult to breathe.
  • Chronic renal disease: in which the kidneys lose their function over time.
  • Coronary artery disease: where the arteries that supply blood to the heart narrow, reducing blood flow to the heart muscle.
  • Crohn’s disease: an inflammatory bowel disease that affects the lining of the digestive tract, causing severe abdominal pain.
  • Diabetes insipidus: a disorder that causes excessive thirst and urination due to a hormonal imbalance.
  • Diabetes mellitus (Type 1 and Type 2): a chronic metabolic condition in which the body’s inability to produce or respond to insulin adequately, causes high blood sugar levels.
  • Dysrhythmia: an abnormal heart rhythm that results in chest pain, and can lead to death in some instances.
  • Epilepsy: a neurological disorder that causes seizures or convulsions of varying intensity and severity.
  • Glaucoma: a type of eye condition that damages the optic nerve and can lead to vision loss or blindness.
  • Haemophilia: a bleeding disorder that impairs blood’s ability to clot.
  • HIV/AIDS: a viral infection that attacks the immune system, leading to a range of symptoms and complications.
  • Hyperlipidaemia: a condition in which there are high levels of fats (lipids) in the blood.
  • Hypertension: high blood pressure that can increase the risk of heart disease and stroke.
  • Hypothyroidism: where the thyroid gland doesn’t produce enough thyroid hormones to meet the body’s needs.
  • Multiple sclerosis: where the nervous system can cause muscle weakness, vision problems, and difficulties with coordination and balance.
  • Parkinson’s disease: a progressive neurological disorder that can cause tremors and difficulty with movement and coordination.
  • Rheumatoid arthritis: an autoimmune disease that causes joint pain and swelling.
  • Schizophrenia: a mental illness characterised by disordered thinking, emotions, and behaviour.
  • Systemic lupus erythematosus: an autoimmune disease that affects organs and tissues in the body, causing symptoms like joint pain and fatigue.
  • Ulcerative colitis: an inflammatory bowel disease that affects the lining of the large intestine, causing severe abdominal discomfort.

Determining if a medical service or treatment is covered by PMBs

If a patient’s medical condition is identified as one of the conditions covered by PMBs, the medical healthcare provider will confirm the diagnosis, treatment, and care related to that condition is eligible for coverage under the Prescribed Minimum Benefits. However, patients should be informed of the extent of their cover under PMBs, as well as any out-of-pocket expenses for which they are responsible. In this manner, members can make informed decisions about their healthcare, along with the financial implications of their treatment.

The Benefits and Limitations of Prescribed Minimum Benefits

The benefits of Prescribed Minimum Benefits (PMBs) include:

  1. Access to essential healthcare services: PMBs are a guarantee that all medical aid members have access to healthcare services, regardless of the specific medical aid plan. In this way, patients receive timely and appropriate care for critical, chronic, or life-threatening conditions.
  2. Guaranteed coverage: Medical schemes are legally required to cover the diagnosis, treatment, and care of the specific medical conditions included in the PMB list. This means that patients can receive necessary healthcare services without worrying about whether their medical scheme will cover the cost.
  3. No waiting periods: This means that patients can receive immediate treatment for their medical condition. This is particularly beneficial for critical and life-threatening conditions where delays in treatment could have serious consequences.
  4. No co-payments or deductibles: Medical schemes are not permitted to charge co-payments or deductibles for the PMB benefits. This means that patients do not have to pay any additional out-of-pocket expenses for the diagnosis, treatment, and care of a covered medical condition.

While PMBs provide essential cover for specific medical conditions, there are also some limitations to these benefits, like:

  1. Limited cover: PMBs only cover the diagnosis, treatment, and care of the specific medical conditions included in the Prescribed Medical Benefits list. Patients may still need to pay for the diagnosis, treatment, and care of other medical conditions or non-PMB medical services.
  2. Limited scope of cover: PMBs only cover the minimum necessary services required. This means that some treatments or interventions may not be covered if they are not considered essential for the specific medical condition.
  3. Limited access to specialists: PMBs may limit access to specialists, as medical schemes are only required to cover the cost of treatment provided by a specialist in cases where it is necessary for the diagnosis, treatment, and care of the specific medical condition.

The way COVID-19 impacted Prescribed Minimum Benefits

The COVID-19 pandemic had a significant impact on PMBs. Some of these included:

  • Increased demand for PMB-covered services. COVID-19 is a serious and life-threatening illness that requires immediate medical attention. As a result, there was an increased demand for PMB-covered services, such as hospitalisation and laboratory tests.
  • Changes in medical protocols and treatments: COVID-19 led to changes for many medical conditions, including those covered under PMBs. Medical schemes revised their policies and procedures to ensure that patients received medical care as quickly as possible.
  • Changes in healthcare delivery: The emergence of online medical resources allowed patients to receive medical care without having to leave their homes.

Affordable medical aid with Prescribed Minimum Benefits

Medical aid members are encouraged to understand the importance of Prescribed Minimum Benefits and to familiarise themselves with the list of PMBs in their scheme so they are fully aware of the extent of the coverage provided by their plan. They can also discuss the matter with a trained consultant to determine the specific benefits available to them under their scheme option. Contact Bloom’s office to get more information about medical aid plans with PMBs.

Medical Content Disclaimer

You understand and acknowledge that all users of the Bloom website are responsible for their own medical care, treatment, and oversight. All content provided on the website, is for informational purposes only and does not constitute medical advice. Neither is it intended to be a substitute for an independent professional medical opinion, judgement, diagnosis or treatment.

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