How To Apply For Chronic Benefits On Your Medical Aid
If you have a long-term condition that has not been registered with your medical aid yet, you are paying for tests and consultations that should be coming out of a different pot. Here is how to fix that.
Imagine two people with the same thyroid condition. They both need the same blood tests every six months. They both see a GP twice a year. They both pay the same medical aid contribution.
One of them pays for all of it from their day-to-day savings. By August, the savings are gone, and they pay out of pocket for everything until January. The other one pays for none of it from savings. Their tests, consultations and condition-related care come from a separate pot called chronic benefits, which exists specifically for long-term conditions like theirs.
The difference between the two is one piece of paperwork: a chronic benefit application, completed and submitted by a doctor.
This guide explains what chronic benefits are, what conditions usually qualify, exactly how the application works, and how Epicentre and our partner doctors can take most of the work off your plate.
If you have a long-term condition, a doctor needs to apply to your medical aid on your behalf with proof of diagnosis. Once approved, your tests, consultations and related medication for that condition come out of your chronic pot, not your day-to-day savings. We can connect you to a partner doctor who handles the application for you.
What Are Chronic Benefits?
Most South African medical aids divide your benefits into separate "pots" that pay for different kinds of care. Chronic benefits are one of these pots, and they are reserved specifically for the ongoing care of registered long-term conditions.
Once a condition is registered, your medical aid covers the related care from this pot instead of from your day-to-day savings. That usually includes:
- Routine blood tests and monitoring tests for the condition
- GP and specialist consultations directly related to the condition
- Approved medication prescribed for the condition
- Certain devices or supplies needed for management of the condition
The exact list depends on your scheme, your plan level, and the condition itself. The principle stays the same across schemes though: condition-related care becomes covered care, and your savings are freed up for everything else.
The 27 PMB Chronic Conditions
South African medical aids must, by law, cover at least 27 chronic conditions on every plan. These are called the Prescribed Minimum Benefits (PMBs), set by the Council for Medical Schemes. Even on the most basic hospital plan, your scheme is legally required to cover the diagnosis and ongoing treatment of these conditions.
Common PMB chronic conditions include:
- High blood pressure (hypertension)
- Type 1 and Type 2 diabetes
- Underactive and overactive thyroid disorders
- Asthma and chronic obstructive pulmonary disease
- High cholesterol (when treatment is needed)
- Epilepsy
- Cardiac failure and certain cardiac conditions
- Chronic kidney disease
- Rheumatoid arthritis
- Bipolar mood disorder and schizophrenia
Many plans cover additional conditions beyond the 27 PMBs, especially on mid-tier and higher plans. The full list for your plan is in your scheme's benefit guide, and our team can help you check which conditions yours covers.
What Specific Tests And Medication Are Covered?
For each PMB chronic condition, the Council for Medical Schemes specifies a minimum "treatment basket": the medication, monitoring tests and consultations every scheme must pay for. Schemes can offer more than the basket but never less.
For example, on a typical hypertension (I10) registration, the basket includes: blood pressure consultations, basic blood tests (urea, electrolytes, creatinine), urine tests, an ECG once a year, and the cost of a standard first-line antihypertensive medication. The exact tests vary by condition.
Schemes publish their own treatment baskets. Discovery's CDL treatment basket document is a useful reference for what is typically covered. Other schemes follow similar patterns. Once you know your ICD-10 code, you can ask your scheme for the treatment basket that applies to your condition, then check that the tests we recommend match what is covered.
Because PMB conditions are required by law, your medical aid cannot refuse to cover them. They can ask for more information during the application, and they can specify which medication or treatments they will pay for, but they cannot say no to a properly diagnosed PMB condition.
Day-To-Day Vs Chronic: A Quick Comparison
To make the difference concrete, here is the same condition handled two different ways:
Out Of Savings
Six-monthly thyroid tests, GP visits and any related medication all come out of your day-to-day savings. Once savings are depleted, you pay out of pocket for the rest of the year. The condition keeps costing you the same amount, but the year keeps getting longer.
Out Of Chronic Pot
The same tests, consultations and medication are claimed against your chronic benefits, which exist specifically for this. Your day-to-day savings stay available for unrelated GP visits, dentistry, optometry and the unexpected things that come up during the year.
The Six-Step Application Process
From start to approval usually takes one to two weeks. The exact timing depends on your scheme and how complete the application is when first submitted.
Confirm Your Diagnosis
Your medical aid will only register a condition that has been confirmed by a doctor with appropriate evidence. That usually means blood tests, clinical findings or specialist reports that prove the condition exists.
If you have not been formally diagnosed yet, this is the first step. Many people suspect they have a condition (chronic fatigue, persistent headaches, weight changes, brain fog) but have never had it confirmed with the right testing.
Get Your ICD-10 Code (And Write It Down)
Every diagnosis has a standard code called an ICD-10 code, used worldwide to classify medical conditions. Your medical aid uses this code to decide which "pot" each claim comes from.
For example, the ICD-10 code for hypertension is I10. For Type 2 diabetes it is E11. For asthma it is J45. Your doctor assigns the code on the application form. Your scheme records it as part of your chronic registration.
Get your code from the approval letter your scheme sends you, or call your scheme and ask. Save it in your phone next to your medical aid number.
Doctor Completes The Application Form
Each medical aid has its own chronic benefit application form, often called a "chronic medication application" or "chronic condition registration". Your doctor fills it in with your diagnosis, ICD-10 code, treatment plan and any supporting test results.
Some schemes require the form to come from a GP, while others accept applications from specialists too. Your doctor will know which form your scheme uses and what it requires.
Submit To Your Medical Aid
The completed form is sent to your medical aid for review. Most schemes respond within 14 working days, although urgent conditions are sometimes assessed faster.
You will usually be notified by SMS or email once your application is received, and again once a decision is made.
Receive Approval Or A Request For More Information
If approved, you receive written confirmation along with your authorised treatment plan. The plan tells you which medication, tests and consultations are covered under your chronic benefits.
If the scheme needs more information, they will write back to your doctor with specific questions. This is normal, especially for borderline diagnoses or applications missing supporting evidence. Your doctor responds with what is needed and the scheme reviews again.
Use Your Chronic Benefits
Once approved, every claim with the matching ICD-10 code is paid from your chronic pot rather than your savings. Your day-to-day savings are now free for unrelated care.
At Epicentre, we need two things from you when you come in for testing related to your chronic condition: your medical aid card and your ICD-10 code. With both, we bill the test directly against your chronic benefit. Without the code, the claim defaults to your day-to-day savings and the chronic pot stays untouched (which is the wrong outcome).
If you do not have the code on hand, call your scheme before you come in and ask for it. They send your registration approval letter by email and post; the code will be there.
No Doctor Yet? We Can Connect You To One.
We work with a network of partner doctors who care about getting your chronic benefits sorted. They can review your case, confirm a diagnosis where appropriate and submit the application for you.
Connect Me With A Partner DoctorCommon Reasons Applications Are Delayed Or Declined
Insufficient supporting evidence
If a doctor submits an application without recent test results or clinical notes, the scheme will usually ask for more information before deciding. This adds days or weeks to the process. The fix is to make sure your testing is recent and complete before the application goes in.
Wrong or unclear ICD-10 code
If the assigned code does not match the evidence, or if a less specific code is used when a more specific one applies, schemes will push back. Experienced doctors who handle chronic applications regularly know which codes pair best with which evidence.
Condition is not on the plan's chronic list
If your condition is not a PMB and is not on your specific plan's extended chronic list, the application will be declined. In that case, you have other options: appeal the decision, upgrade your plan at renewal, or claim from a different benefit. Our team can talk you through what makes sense for your situation.
Not following the scheme's specific process
Different schemes have different forms, different submission channels and different documentation requirements. Submitting through the wrong channel or using an outdated form is one of the most common causes of delays. This is one of the biggest reasons working with a doctor familiar with the application process saves time.
What If My Application Gets Declined?
A decline is not the end of the road. You have three options:
- Appeal. Your doctor can submit additional evidence and request a review. For PMB conditions, this is often the right next step because the scheme is legally obliged to cover them.
- Re-apply later. If your condition needs more time or testing to confirm, your doctor can re-apply once the evidence is stronger.
- Use other benefits. Some testing might still be claimable under preventative benefits or your day-to-day savings while you sort out the chronic application. Read more about preventative benefits here.
How Epicentre Helps
Most labs leave you to figure all of this out yourself. We do not.
If you already have an approved chronic application, all you do is bring your medical aid card to any Epicentre branch. We check which benefit each test should be claimed against and submit the claim for you. You only pay the difference, if any.
If you do not yet have an approved application, we can connect you to a partner doctor in our network. These doctors care about chronic benefit applications, know the forms and processes for every major scheme, and will handle the application on your behalf. From your first appointment to approval, you do not need to chase paperwork or learn scheme-specific jargon. They handle it.
Either way, there is no extra charge from Epicentre for this support. It is part of what we do.
The Bottom Line
If you have a long-term condition and you are paying for related care from your day-to-day savings, you are spending money that should be coming from a separate pot of medical aid funds. The application process to fix that is straightforward, and you do not have to do it alone.
Start by working out what you need. If you have a clear diagnosis and just need an Epicentre branch to claim correctly, book a test and bring your medical aid card. If you need a doctor to confirm a diagnosis or handle the application, we can connect you to one of our partner doctors who does this every day.
Stop Paying For Chronic Care From Day-To-Day Savings
If you have a long-term condition, your medical aid probably has a separate pot of money waiting to cover it. We can help you unlock it.
