Overview of Prescribed Minimum Benefits (PMBs)
In South Africa, Prescribed Minimum Benefits (PMBs) are a set of defined medical benefits guaranteed by law under the Medical Schemes Act 131 of 1998. PMBs ensure that all medical aid scheme members—regardless of their specific benefit option or plan level—have access to continuous minimum healthcare coverage for critical health conditions without depleting their daily savings or out-of-pocket benefits.
Under South African healthcare legislation, medical aid schemes are required to pay in full for the diagnosis, treatment, and ongoing care of all PMB-qualifying conditions, provided the member adheres to the scheme’s regulations and designated provider networks.
What Conditions Are Covered under PMBs?
PMB coverage is divided into three primary categories:
1. Emergency Medical Conditions
An emergency medical condition is defined as the sudden and unexpected onset of a health condition that requires immediate medical or surgical treatment. Failure to provide immediate treatment could result in serious impairment to bodily functions or pose a threat to life.
2. Diagnosis and Treatment Pairs (DTPs)
There are 271 Diagnosis and Treatment Pairs listed in the regulations. These cover a broad range of serious medical conditions, including:
- Acute infections (e.g., severe pneumonia, appendicitis)
- Cancers and malignant tumors
- Severe traumatic injuries and fractures
- Organ failure (e.g., kidney failure, cardiac arrest)
- Stroke and cardiovascular emergencies
3. Chronic Disease List (CDL)
The CDL mandates full coverage for diagnosis, treatment, and chronic medication for 26 defined chronic conditions:
- Addison’s disease
- Asthma
- Bipolar mood disorder
- Bronchiectasis
- Cardiac failure
- Cardiomyopathy
- Chronic obstructive pulmonary disease (COPD)
- Chronic renal (kidney) disease
- Coronary artery disease
- Crohn’s disease
- Diabetes insipidus
- Diabetes mellitus (Type 1 and Type 2)
- Dysrhythmias (irregular heart rhythm)
- Epilepsy
- Glaucoma
- Haemophilia
- Hyperlipidaemia (high cholesterol)
- Hypertension (high blood pressure)
- Hypothyroidism
- Multiple sclerosis
- Parkinson’s disease
- Rheumatoid arthritis
- Schizophrenia
- Systemic lupus erythematosus (SLE)
- Ulcerative colitis
- Dysrhythmic heart conditions
Rules for Accessing Full PMB Funding
To ensure that your medical aid covers PMB claims at 100% of the cost without co-payments, members must follow these key rules:
- Designated Service Providers (DSPs): Medical schemes appoint specific hospitals, specialists, general practitioners (GPs), and pharmacies as DSPs. Unless it is a life-threatening emergency or a DSP is not accessible, you must use your scheme’s DSP for treatment and medication.
- ICD-10 Diagnostic Codes: Healthcare providers must include the correct ICD-10 diagnostic codes on all treatment authorizations, prescriptions, and account claims to verify that the condition qualifies for PMB status.
- Formularies and Clinical Protocols: Medical aids maintain approved medicine lists (formularies) and treatment protocols for chronic PMB conditions. If a member requests non-formulary medication without a clinical motivation, co-payments may apply.
Medical Aid PMB Contact Details Directory
Below are the submission email addresses, customer service contact numbers, and official websites for PMB applications and chronic disease benefit registrations across South African medical schemes.
| Medical Aid Scheme | PMB / Chronic Submissions Email | Contact Hotline | Official Website |
| Discovery Health | [email protected] | 0860 99 88 77 | www.discovery.co.za |
| Bonitas Medical Fund | [email protected] | 0860 00 21 08 | www.bonitas.co.za |
| Momentum Health | [email protected] | 0860 11 78 59 | www.momentumhealth.co.za |
| Bestmed Medical Scheme | [email protected] | 0860 00 23 78 | www.bestmed.co.za |
| Medshield Medical Scheme | [email protected] | 0860 00 21 21 | www.medshield.co.za |
| Fedhealth | [email protected] | 0860 00 21 53 | www.fedhealth.co.za |
| GEMS (Government Employees) | [email protected] | 0860 00 43 67 | www.gems.gov.za |
| LA Health Medical Scheme | [email protected] | 0860 10 39 33 | www.lahealth.co.za |
| CMP Medical Aid | [email protected] | 0800 132 345 | www.cmp.co.za |
Step-by-Step PMB Application Process
- Download the Application Form: Access the official PMB or Out-of-Hospital Disease Management application form from your scheme’s online portal or app.
- Consult Your Medical Practitioner: Have your attending doctor or specialist complete the clinical sections of the form, ensuring all appropriate ICD-10 diagnostic and treatment codes are recorded.
- Attach Supporting Documents: Include required clinical proof, such as lab blood results, radiology reports, or biopsy findings.
- Submit for Processing: Send the completed paperwork directly to your scheme’s dedicated PMB email address.
- Track Confirmation: Save your submission reference number. Scheme review periods typically range between 7 to 14 business days.
Escalations and Regulatory Complaints: Council for Medical Schemes (CMS)
If a medical scheme denies coverage for a valid PMB condition, short-pays an invoice, or fails to resolve a dispute within 30 days, members can escalate the issue to the Council for Medical Schemes (CMS). The CMS is the statutory body regulating all registered private healthcare financing in South Africa.
CMS Contact Information
- Customer Care Centre: 0861 123 267 (0861 123 CMS)
- General Enquiries:
[email protected] - Complaints Department:
[email protected] - Fax: (086) 673 2466
- Website:www.medicalschemes.co.za
- Physical Address: Block A, Eco Glades 2 Office Park, 420 Witch-Hazel Avenue, Eco Park, Centurion, 0157
- Postal Address: Private Bag X34, Hatfield, 0028