What Are Prescribed Minimum Benefits (PMBs)?
The benefits your medical scheme cannot legally refuse, even on a hospital plan. Plus how to actually claim them.
Most people on a medical aid have no idea what PMBs are. Most doctors will not bring them up. Most scheme call centres will not volunteer them. And yet PMBs are the strongest patient protection in South African medical aid law: a defined list of conditions and emergencies your scheme is legally obliged to cover in full, no matter how broke your day-to-day savings are or how basic your plan.
If you have ever been told "your plan does not cover this", or "you are out of savings, you will have to pay yourself", and the situation involved something serious or chronic, there is a real chance you were entitled to a PMB benefit you never knew existed.
This guide explains what PMBs are, what they cover, how to claim them, and what to do when a scheme tries to wriggle out of paying.
Every South African medical scheme must, by law, cover the diagnosis, treatment and ongoing care of any life-threatening emergency, 270 defined serious conditions and 27 chronic conditions on the Chronic Disease List. They cannot refuse, and they cannot put a rand cap on these benefits. The catch is in the fine print: you usually need to use a Designated Service Provider, and the right paperwork has to be in order.
What Are PMBs, Exactly?
Prescribed Minimum Benefits are a statutory framework set out in the Medical Schemes Act 131 of 1998 and its regulations. The framework is administered by the Council for Medical Schemes (CMS), the South African statutory body that regulates the entire medical scheme industry.
The principle is simple: every medical scheme registered in South Africa must cover a defined minimum set of conditions, regardless of the member's plan, contribution level or remaining benefits. PMBs sit above the rest of your scheme's benefit structure. They are not optional extras and they are not subject to your day-to-day savings running out.
The Three Things PMBs Cover
The framework covers three categories of care:
1. Any Life-Threatening Emergency
If you arrive at any emergency room with a life-threatening condition, your scheme must pay for stabilisation and the immediate care needed to get you out of danger. This applies even if the hospital is not on your plan, even if you have used all your savings, and even if the emergency turns out to be something not on the regular PMB list. The legal test is whether a reasonable person would have considered the situation an emergency at the time.
2. The 270 Defined Serious Conditions
The CMS publishes a list of 270 specific medical conditions, each described in detail with the minimum level of care that schemes must provide. These cover serious illnesses across cancer, cardiovascular disease, neurological conditions, infections, autoimmune disease and many other categories. The list is technical and condition-specific, but the principle is the same throughout: if you are diagnosed with one of these, your scheme must cover the defined level of treatment.
3. The 27 Chronic Conditions On The CDL
The Chronic Disease List (CDL) contains 27 long-term conditions that schemes must cover for ongoing management. This is the part of the PMB framework most people interact with. The list includes:
- Hypertension (high blood pressure)
- Type 1 and Type 2 diabetes
- Asthma and chronic obstructive pulmonary disease
- Hypothyroidism and hyperthyroidism
- Hyperlipidaemia (high cholesterol when treatment is needed)
- Epilepsy
- Cardiac failure and certain other cardiac conditions
- Chronic kidney disease (chronic renal failure)
- Rheumatoid arthritis
- Bipolar mood disorder and schizophrenia
- HIV (under specific PMB protocols)
For each condition on the CDL, the regulations specify a minimum "treatment basket": the consultations, monitoring tests and medication that the scheme must pay for. Discovery publishes its CDL treatment baskets here, and other schemes follow similar patterns. Once you know which CDL condition applies to you, you can ask your scheme for the relevant treatment basket and check what is covered.
The Legal Protection: What Schemes Must Do
Three protections are worth knowing about because schemes will sometimes try to ignore them:
Schemes must pay in full. PMB conditions cannot have a rand cap on them. If your scheme says "we have paid up to your annual limit", that does not apply to PMB care. The benefit must continue without limit for the duration of treatment.
Hospital plans are included. Even on the most basic hospital plan, PMBs apply. People are sometimes told "you only have hospital cover, you do not get day-to-day testing" and given up on. This is wrong if the testing is for a PMB diagnosis or condition.
Day-to-day savings are not relevant. Whether your savings are full, half-used or completely depleted, the scheme still has to cover PMB care. PMBs are not paid from your savings pot; they are paid from a separate scheme obligation.
If a call centre agent tells you "this is not covered" and the situation involves anything serious, ask specifically: "Is this not a PMB?" Sometimes it is, and the agent simply did not check.
The Fine Print: What Schemes Are Allowed To Do
The PMB framework is not a blank cheque. Schemes have several legitimate ways to manage cost, and these are where most disputes come from.
Designated Service Providers (DSPs)
Schemes can contract with specific doctors, hospitals, pharmacies and pathology labs to deliver PMB care. These contracted providers are called Designated Service Providers. If you use a DSP, your scheme pays in full. If you use a non-DSP when one was reasonably available, the scheme is allowed to charge you a co-payment.
The exception: in a true emergency or where no DSP is reasonably available, the scheme must still pay in full at any provider. The "reasonably available" test depends on the situation, and the burden is on the scheme to prove a DSP was accessible.
Treatment Protocols And Formularies
Schemes can specify which medication and treatment options they will pay for, as long as the protocol provides effective care for the condition. If your doctor wants to use a more expensive option than the scheme's formulary, the scheme can ask for clinical justification or charge you the difference.
The formulary cannot be unreasonably restrictive. If the scheme's preferred treatment is medically inappropriate for you, the scheme must approve the alternative.
Pre-authorisation
Most schemes require pre-authorisation for PMB-related procedures, hospital admissions and certain expensive tests. Skipping pre-authorisation can result in part of the cost being deducted from your day-to-day savings instead, even if the underlying care was a PMB. In emergencies, retrospective authorisation is allowed, but you have to apply for it within the scheme's timeframe.
How To Claim A PMB
Unlike preventative or chronic benefits, PMBs do not have a single application form. They apply automatically when the right conditions are met. The trick is making sure they get applied. Here is how.
Confirm The Diagnosis Is A PMB
Before any major test or procedure, ask your doctor whether the working diagnosis is a PMB condition. For chronic conditions, the answer is usually yes if it is on the CDL. For other situations, the test is whether the diagnosis matches one of the 270 defined serious conditions or is a life-threatening emergency.
If your doctor is unsure, ask them to check. The CMS website lists every PMB condition with its diagnostic criteria.
Get The Right ICD-10 Code
Every PMB condition is identified by one or more ICD-10 diagnosis codes. The code must be on every claim for the scheme to recognise it as a PMB. Wrong code, wrong outcome. If your doctor uses a generic or vague code when a PMB-specific code applies, the scheme will assess the claim under your day-to-day savings, not under PMBs.
Ask your doctor to use the most specific applicable code, and write it down. You will need it for follow-up care, prescriptions and any subsequent tests.
Use A DSP Where Possible
Find out who your scheme's Designated Service Providers are for the type of care you need. Most schemes publish DSP networks on their website or member portal. For PMB-related testing, look up the pathology lab DSPs. For specialist consultations, check the specialist DSPs.
If a DSP is reasonably accessible, use them. If you cannot reach a DSP without serious inconvenience or delay, document why, then use a non-DSP and submit the reason with the claim. The scheme can be challenged on co-payments imposed unreasonably.
Submit The Claim Marked As A PMB
When the doctor or lab submits the claim, they should explicitly mark it as a PMB claim, with the relevant ICD-10 code and a note linking the test or treatment to the PMB condition. Some schemes have a specific PMB claim form; others allow PMB flagging on the standard claim. Either way, "this is a PMB claim" should be visible somewhere on the paperwork.
If the claim comes back paid from your day-to-day savings, that is a sign the PMB flag did not get applied. Time to push back.
Push Back If The Claim Is Refused Or Misclassified
Schemes are not infallible, and sometimes refusal is the default response unless you challenge it. If your claim is paid from savings instead of PMBs, or refused entirely on a PMB-eligible condition, write to the scheme citing the PMB regulations and ask for the assessment to be reviewed. Reference the specific condition, the ICD-10 code and the relevant section of the PMB framework.
If the scheme does not budge, the next step is escalating to the CMS itself, which has a complaints process specifically for PMB disputes.
We Can Check If Your Tests Qualify As PMBs
When you book testing with us, we check whether your situation falls under PMBs. If it does, we make sure the claim is submitted with the correct flag and ICD-10 code so your scheme pays in full.
Ask Us To CheckDay-To-Day Vs PMB: A Quick Comparison
To make the difference concrete, here are two ways the same diagnostic test can play out:
Without PMB Flag
You go for a blood test that turns out to be diagnosing a PMB condition. The lab submits the claim under a generic ICD-10 code. The test gets paid from your day-to-day savings. By August your savings are depleted, and you pay out of pocket for follow-up tests, GP visits and any unrelated care for the rest of the year.
With PMB Flag
The same test, but the doctor uses the PMB-specific ICD-10 code and the lab submits it as a PMB claim. The scheme pays in full from the PMB obligation, not from your savings. Your savings stay intact for everything else, and follow-up tests for the same condition continue to be paid as PMBs.
Common Reasons Schemes Refuse PMB Claims
The diagnosis is unclear or generic
If the claim uses an ICD-10 code that does not specifically match a PMB condition, the scheme will assess it under regular benefits. The fix is to ask your doctor to review the diagnosis and use the most specific applicable code.
Treatment is outside the scheme's protocol
If the prescribed treatment is more expensive than the scheme's formulary alternative, the scheme can refuse to pay the full cost. The fix is either to use the scheme's preferred treatment, or to provide clinical justification for why the alternative is medically necessary.
A non-DSP was used
If a DSP was reasonably available and you used someone else, the scheme can charge a co-payment. The fix is to switch to a DSP for ongoing care, or to document why the DSP was inaccessible at the time.
Pre-authorisation was missed
Some PMB-related procedures require pre-authorisation. Going ahead without it can result in a co-payment or a refusal. The fix is to apply retrospectively if the scheme allows, or to use pre-authorisation properly for all future care.
What If The Scheme Still Will Not Pay?
If your scheme refuses a PMB claim and you believe it is wrong, you have three escalation options:
- Internal appeal. Most schemes have a formal appeals process. Submit your appeal in writing with all supporting documentation, citing the PMB regulations.
- CMS complaint. The Council for Medical Schemes investigates PMB disputes specifically. They have the power to compel schemes to pay where the law clearly applies.
- Legal action. In persistent cases, schemes can be taken to court for non-compliance with the Medical Schemes Act. This is rare but it does happen, and successful claimants have had refused payments restored with interest.
Most disputes resolve at the internal appeal stage with the right paperwork. The CMS complaint route is for cases where the scheme is being unreasonable.
How Epicentre Helps With PMB Diagnostics
The diagnostic side of PMBs is where we play a role. When you come to us for testing that is part of diagnosing or monitoring a PMB condition, we can:
- Check the situation against the PMB framework before any tests are run, so you know whether to expect full coverage
- Submit the claim with the correct ICD-10 code and PMB flag, so the scheme processes it properly the first time
- Liaise with our partner doctors when a clearer diagnosis is needed to unlock PMB cover
- Give you the documentation you need to push back if the scheme misclassifies the claim
There is no extra charge for any of this. It is part of how we handle medical aid claims.
The Bottom Line
PMBs are the most powerful protection in South African medical aid law, and the least well understood by members. If you have ever been told your scheme will not cover something serious, or that you have run out of savings during a chronic illness, there is a real chance you had a PMB right that nobody applied.
Three things to remember: the right ICD-10 code, the use of a Designated Service Provider where possible, and the willingness to push back when a claim is misclassified. With those three, most PMB disputes resolve in the member's favour.
If you are not sure whether your situation qualifies, ask. We can check, your doctor can check, and ultimately the scheme can be made to check.
Make Sure You Get The PMBs You Are Entitled To
Book your test, bring your medical aid card and let us handle the rest. We check whether your situation falls under PMBs before any tests are run.
