PMBs or prescribed minimum benefits are defined conditions and treatments which must be provided, by law, to all medical aid scheme members and beneficiaries in full and without co-payment, regardless of the benefit option selected. Introduced by the Medical Aid Schemes Act in 2004, PMBs ensure members of schemes have access to minimum health services at all times and are not forced to seek treatment in state hospitals because they have run out of benefits for a specific treatment or condition.
These mandatory PMBs cover approximately 270 limited conditions including medical emergencies, cardiac treatment, menopausal management and the treatment of a cluster of cancers, as well as 26 chronic conditions such as HIV and AIDS.
When Are PMBs Not Applicable?
When you apply for medical aid cover you undergo a process of medical underwriting which assesses whether you are insurable according to your medical history. There are traditionally three underwriting categories. If you fall into category one, you are not entitled to PMB cover as you have:
- Never belonged to a medical aid scheme before.
- Allowed more than 90 days to elapse between joining the new scheme and leaving the previous one.
Other Rules Covering PMBs
- Medical aid scheme rule exclusions do not apply to PMBs. A prescribed minimum benefit is concerned with the diagnosis of the condition, regardless of how it was contracted.
- If you choose not to use a Designated Service Provider or DSP - your medical scheme’s preferred health care provider – for the treatment of a PMB condition, you may have to pay a portion of the claim, known as a co-payment.
- Your medical aid scheme can insist you obtain pre-authorisation or join a benefit management programme before your PMB cover comes into effect.
The following conditions have been classified as PMB conditions by the Board of Healthcare Funders of Southern Africa:
|PMB Conditions on the Chronic Disease List|
• Addison’s Disease
• Multiple Sclerosis
• Parkinson’s Disease
• Rheumatoid Arthritis
• Systemic Lupus Erythematosis
• Ulcerative Colitis