Let’s help you unlock the benefits you’re already paying for — and make your cover work for you. If you’ve ever tried to figure out what your medical aid really covers, you’ve probably heard the term Prescribed Minimum Benefits — or PMBs.
It can be confusing, especially because each medical aid can set different limits for the number of tests and visits they allow each year. But here’s the important part: all medical schemes must follow the basic PMB rules set by the Council for Medical Schemes.
What Are PMBs?
PMBs are a set of rules in South Africa’s Medical Schemes Act that make sure every medical scheme member has access to essential healthcare — no matter what plan you’re on.
By law, your medical aid must cover the diagnosis, treatment, and care for:
1. Any emergency medical condition – a life-threatening emergency that needs immediate treatment.
2. 27 chronic conditions – listed in the Chronic Disease List (CDL), such as diabetes, high blood pressure, asthma, and epilepsy.
3. 271 medical conditions – called Diagnosis Treatment Pairs (DTPs), which link specific diagnoses to the minimum care your scheme must fund.
PMBs Go Beyond the CDL List
When people think about PMBs, they often think only about the 27 chronic diseases on the CDL list. But PMB cover extends to many other medical conditions — even if they’re not considered emergencies and don’t appear on the CDL list.
These can include conditions that need ongoing treatment or regular monitoring. They fall into 15 broad categories, such as:
• Cancer (whether you’re in active treatment, in remission, or just being monitored)
• Neurological conditions (like multiple sclerosis or Parkinson’s disease)
• Cardiovascular issues (heart problems, heart failure)
• Blood disorders
• Urological conditions
• Gynaecological conditions
• Gastro-intestinal conditions
• Musculoskeletal disorders
• …plus 8 other categories defined in the regulations
How Does Your Scheme Know It’s a PMB?
Every medical condition is assigned a diagnosis code called an ICD-10 code.
• If your ICD-10 code matches one on the PMB list, your treatment should be covered under PMBs.
• If it doesn’t, it may come from your savings or day-to-day benefits instead.
💡 Tip: Always ask your healthcare provider to include the correct ICD-10 code on your claim — it’s the key to getting the right coverage.
Tips to Make the Most of PMB Cover
1. Ask if your diagnosis qualifies as a PMB – don’t assume it doesn’t just because it’s not on the CDL list.
2. Get registered – for many PMB conditions, your provider must register you with your scheme to unlock ongoing benefits.
3. Know your designated service providers (DSPs) – using your scheme’s network doctors, hospitals, and pharmacies can mean your PMB care is paid in full.
4. Ask about your “basket of care” – once registered, your condition might entitle you to specific tests, scans, and doctor visits each year without touching your savings.
5. Keep records – track your approvals, correspondence, and benefit usage.
Why This Matters for You
PMBs exist to protect you — so that essential care is available whether you’re on the cheapest hospital plan or a top-tier option.
If you think you might have a PMB condition, speak to your healthcare provider about registering it with your medical aid. You could unlock additional tests, specialist visits, and treatments you’re already entitled to — without extra costs.
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 |
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
