Let’s help you unlock the benefits you’re already paying for — and make your cover work for you.
Many South Africans pay for medical aid every month but don’t fully understand how to use it. Because of this, thousands miss out on free tests, chronic medication, and even specialist consultations — simply because they aren’t properly registered or aware of what’s included.
At Epicentre, we want to help you use your medical aid the smart way. Let’s break down the basics and show you how to save money and protect your health.
Understanding Your Medical Aid: The Three Main Benefit Types
Here’s how most medical schemes structure their benefits:
1. Preventive Benefits
These are routine check-ups and tests designed to detect problems early.
• Usually do not come from your savings
• Examples include: Blood pressure checks, cholesterol testing, flu shots, Pap smears, HIV screening, and wellness assessments
These benefits are usually listed in your annual wellness allowance or screening benefit. You don’t need to be ill to use them.
2. Prescribed Minimum Benefits (PMBs)
By law, all South African medical aids must cover:
· 271 medical conditions
· 27 chronic conditions (called the Chronic Disease List or CDL)
This includes diagnosis, treatment, and ongoing care — even if you’re on a basic hospital plan.
✅ PMBs must be fully covered if:
· You’re registered for the condition
· You use your medical aid’s designated service providers (DSPs)
· Your claims use the correct diagnosis codes (ICD-10)
3. Chronic Illness Benefits (CIB)
This is where many people miss out. If you’ve been diagnosed with a chronic condition like:
• Hypertension (High blood pressure)
• Diabetes (Type 1 or 2)
• Asthma
• Cardiac failure
• Hyperlipidaemia (High cholesterol)
• Hyperthyroidism
• …or one of 27 total conditions on the CDL list
— You can register for the Chronic Illness Benefit. This gives you access to a “basket of benefits” that includes specific medications, tests, and specialist visits, all covered either fully or partially by your chronic benefits (not your day-to-day savings), as long as claims are correctly submitted.
What’s in This “Basket of Benefits”?
The exact benefits depend on your condition and scheme, but typically include:
• Routine blood tests (e.g. HbA1c, cholesterol, thyroid tests etc…)
• Regular GP and/or specialist consultations
• Annual eye exams or ECGs (if clinically required)
• Chronic medication
• Access to healthcare professionals like dietitians or diabetes educators
For example, a patient with diabetes may be eligible for:
• 4 x HbA1c tests per year
• Annual lipid and glucose panels
• 1 x eye exam per year
• 4 x GP visits related to diabetes
• Access to a diabetes educator and registered dietitian
• Chronic medication is fully covered by the plan
How to Access Your Chronic Benefits
Step-by-Step:
1. Get Diagnosed
See your GP or specialist for an official diagnosis and supporting test results.
2. Submit the Chronic Illness Benefit (CIB) Application
Your doctor must fill in the Chronic Illness Benefit form and submit it with the relevant ICD-10 codes.
3. Wait for Approval
Your medical aid will confirm your registration and send a breakdown of your chronic benefits.
4. Nominate a GP (if required)
Some schemes require you to select a primary doctor. You can usually change this 2–3 times a year.
5. Use the Right Codes (VERY IMPORTANT)
⚠️ Always include the correct ICD-10 code when submitting claims related to your condition. This ensures the cost comes from your chronic benefit, not your savings.
Quick Reference Table
| Benefit Type | Covers | Do You Need To Register? |
|---|---|---|
| Preventative Benefits | Check-ups, Screenings | X No registration needed |
| PMB | Emergencies & chronic conditions | ✅ Yes – must register and follow rules |
| Chronic Benefits | Ongoing tests, meds, specialist care | ✅ Yes – register & apply through your doctor |
Do Your Own Check-In
We’ve done our research — and based this blog on publicly available documents from medical aid companies— but it’s essential to confirm your cover directly with your provider and ensure your registered ICD10 code is on all claims from providers
Call your scheme and ask:
• “Am I registered for any Chronic Conditions/ Prescribed Minimum Benefits?”
• “If not, how do I apply?”
• “What tests and treatments are covered for X condition?”
• “Do I need to use specific doctors or pharmacies?”
• “How can I view my benefits and claims online?”
• “What ICD-10 codes should my provider use for this condition?”
Let’s Keep the Conversation Going
At Epicentre, we’re here to help you take charge of your health — and that includes making the most of your medical aid. Over the next few weeks, we’ll be sharing more practical tips in our Saving with Medical Aid Series, including:
· How to avoid depleting your savings for basic care
· How to register for PMBs and get full cover
· What to check before booking tests or specialists
Follow us on social media @epicentre_za to stay in the loop.
Written in collaboration with Practice Solutions — helping healthcare providers with practice management solutions so that they can focus on patient care. To learn more about their services, visit www.medpracsol.co.za
References
Patil, S., & Mehdi, S. S. (2025). The Gut-Brain Axis and Mental Health: How Diet Shapes Our Cognitive and Emotional Well-Being. Cureus, 17(7), e88420.
Rathore, K., Shukla, N., Naik, S., Sambhav, K., Dange, K., Bhuyan, D., & Haq, Q. M. I. (2025). The Bidirectional Relationship Between the Gut Microbiome and Mental Health: A Comprehensive Review. Cureus, 17(3), e80810.
Leao, L., Miri, S., & Hammami, R. (2025). Gut feeling: Exploring the intertwined trilateral nexus of gut microbiota, sex hormones, and mental health. Frontiers in Neuroendocrinology, 76, 101173.
