What are PMB’s?

What are PMB’s?

Doesn’t it feel like your medical aid is paying less and less but your contribution towards the scheme is soaring? If you belong to a private medical aid scheme in RSA, I can guarantee you that each year you are getting less bang for your buck! It’s a tough pill to swallow isn’t it? What’s hurts even more is that your choice of medical aid plan is based solely on your affordability. Fatter wallets get access to wider private health care choices and better coverage. Skinny wallets, trying to negotiate a tricky budgeting tight rope each month, have fewer plan options. But surely medical aid schemes should be picking up the costs of certain conditions regardless of what plan you are on?

Yes, they should and, by law, they must. Medical Aid Schemes in this country are legally obliged to pay for in full the treatment of certain conditions regardless of plan type. I’m referring to a list of “Prescribed Minimum Benefits” or PMB’s and this is what you need to know about them.

PMb’s were introduced in line with the Governments Health Policy and since 2004 medical schemes have been required to fund the costs of PMB medicine, cover the cost of reasonable tests to confirm the PMB condition or disease and all costs associated with descriptions of PMB treatment as set out in law.

So what’s actually covered in this PMB list?

The Prescribed Minimum Benefit list covers:

1) Emergency Conditions

2) Chronic Disease List

There are just too many conditions to list in this post, so I would suggest that you download a copy of the PMB list after reading this post. A link to the PMB list will be provided at the end of this article.

How can I be sure that my Medical Aid Scheme is going to pay for these PMB’s in full?

Now that’s a good question. You don’t need to worry about your scheme paying for these costs in full because by law they are obliged to.

The Regulations of the Medical Schemes Act of 1998 clearly states:

“Prescribed Minimum Benefits.—(1) Subject to the provisions of this regulation, any benefit option that is offered by a medical scheme must pay in full, without co-payment or the use of deductibles, the diagnosis, treatment and care costs of the prescribed minimum benefit conditions.”

You don’t need to take my word for it..

A copy of the Regulations of the Medical Schemes Act of 1998 is available for download. Click here to download the document.

What you do need to make sure of is that the treatment of your PMB falls within the parameters afforded to your medical aid scheme by government.

You see, before PMB’s were made compulsory medical aid schemes could control their liabilities by simply listing commonly required treatments for emergencies and chronic diseases in more expensive plan options. So as a scheme member you might not have had these conditions covered in full unless you paid extra to be on a more comprehensive plan. The real problem is that no medical scheme could afford to fund PMB’s with no limits in place. The law had to provide options to medical aid schemes to ensure the costs to the schemes are manageable:

Today Medical Aid Schemes can:

1) Appoint Designated Service Providers  (DSP’s)

2) Have formularies (medicine lists) & treatment plans in place for PMB’s

So what does that mean to you?

The cost of the PMB will be covered by your medical aid scheme provided that you use a designated service provider. If you don’t use a provider chosen by your scheme, the scheme can impose a co-payment. That of course means that the PMB isn’t going to be covered in full because you will be liable for a partial payment.

The Medical Schemes Act of 1998 says the following:

“The diagnosis, treatment and care costs of a prescribed minimum benefit condition will only be paid in full by the medical scheme if those services are obtained from a designated service provider in respect of that condition.”

The scheme is also allowed to have their own treatment protocols in place for PMB’s and their own medicine lists. That simple means the scheme can choose how they are going to treat the PMB condition and which treatment plan to follow. There aren’t however allowed to use funds in your medical savings accounts to pay for the costs of PMB treatment!

Your medical aid is a vital bit of insurance. Make sure that you know which PMB conditions your medical aid scheme is obliged to pick up in full.

A copy of the PMB list is available here for download. Click here now. See Annexure A of the Regulations of the Medical Schemes Act of 1998 Page 31/59 of the PDF.

If you would like to leave a comment, please do so below.

Until Next Time

Comments on this entry are closed.

Warning: include_once(/home4/fundi/public_html): failed to open stream: Success in /home4/fundi/public_html/wp-content/themes/thesis/lib/core/skin/boxes.php on line 1968

Warning: include_once(): Failed opening '' for inclusion (include_path='.:/opt/php54/lib/php') in /home4/fundi/public_html/wp-content/themes/thesis/lib/core/skin/boxes.php on line 1968
Next Post : Prev Post :

Get an Altrisk life quote

Click here to get an Altrisk life insurance quote.

Client Testimonials

"Thank you very much to you all. You guys have made my day and year. Now I can rest easy knowing my family will be looked after should anything unforeseen happen to me. You guys are awesome!"
- Caroline Ferreira

"Hi Brendan. Thanks for getting my short term insurance claim sorted out so promptly."
- Becky Smith

"Thanks guys, you are fabulous, everything was so easy and you guys are super quick. It really is a pleasure dealing with all of you."
- Noleen Whitting

"Thanks to Brendan and Gill for all their efforts!"
- Nick Magowan

"Thanks for your excellent service I got from your company."
- Musa Khumalo

"Thank you for your prompt service."
- Chris Beater

"My sincere thanks to both Brendan and Lawrence for the excellent manner in which they dealt with my many questions asked regarding taking out this life insurance policy, and especially the promptness to which they always came back when I queried anything, and for the advice. It was a pleasure dealing with you all, and will use your company for any further insurance needs that I or my staff may require in the future."
- Jill Van Der Lingen

"Thanks for your professionalism and swift action!"
- Tendai Chingonzoh

"Thanks for all your help."
- Carol Kotze

"You have no idea how long I have been battling to find good life insurance. I have received numerous quotes, but nobody has been as helpful as you guys. Thanks a million"
- Shahieda Barnwell

"You guys are the best insurance brokers imaginable! I cannot thank you enough for sorting out our complicated claim so speedily. In today's world your efficiency and professionalism are a rare find. So the HUGEST thanks once again and best wishes for the continuation of your successful business."
- Ingrid Loud

"My sincere appreciation to Lawrence and Brendan for all their help."
- Vicent Morodi

%d bloggers like this: