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Medical Aid Questions Answered

What are prescribed minimum benefits? (PMBs)

Prescribed Minimum Benefits (PMBs) are a set of pre-defined conditions that all medical schemes in South Africa have to cover, by law. They form part of the Medical Schemes Act, with the aim being to ensure that the wellbeing and health of South African medical aid members is safeguarded and that healthcare is more affordable.

The existence of PMBs means that anyone who is part of a medical scheme, no matter what plan they’re on, can receive treatment for 270 hospital-based and 25 chronic conditions and that the cost of these will be covered in full. PMBs also cover any kind of emergency treatment and include certain out-of-hospital treatments.

How does a doctor decide if my condition will be covered by a PMB?

 Your doctor will look purely at your symptoms to decide on this, making the decision diagnosis-based. They won’t look at how the condition was contracted in the first place, but rather the symptoms you are displaying at that current point in time. They will then decide where you should receive the treatment, either in the doctor’s rooms or in-hospital.

What kind of conditions does it cover?

 You can read the full list of hospital-based conditions covered, which are grouped into 15 broad categories and include things like heart attacks, strokes and pneumonia. The 25 chronic diseases in the PMBs include conditions like epilepsy and bipolar mood disorder – read the full list.

Where can I get help with a PMB related issue?

The Council for Medical Schemes (CMS) was established to supervise medical schemes in South Africa and exists to protect your rights as a consumer to be treated fairly. If you need help with a PMB issue, contact them for guidance.