What are Prescribed Minimum Benefits?

Prescribed Minimum Benefits (PMBs) are a set of defined benefits to ensure that all medical scheme members have access to certain minimum health services, regardless of the benefit option they have selected. The aim is to provide people with continuous care to improve their health and well-being and to make healthcare more affordable.

PMBs are a feature of the Medical Schemes Act, in terms of which medical schemes must cover the costs related to the diagnosis, treatment and care of:

• any emergency medical condition;
• a limited set of 271 medical conditions (defined in the Diagnosis Treatment Pairs); and
• 26 chronic conditions (defined in the Chronic Disease List).

When deciding whether a condition is a PMB, the doctor should only look at the symptoms and not at any other factors, such as how the injury or condition was contracted. This approach is called diagnosis based. Once the diagnosis has been made, the appropriate treatment and care is decided upon as well as where the patient should receive the treatment (at a hospital, as an outpatient or at a doctor’s rooms).

Note: The Council for Medical Schemes (CMS) would like to bring to your attention the publication of the new PMB Coded List. Clinical Review Committee members have established that the 2013 PMB and ICD-10 Coded List needs to be updated to include previously omitted ICD-10 codes and COVID-19. The changes are implemented with immediate effect. Please see the updated PMB Coded List ABOVE, along with a summary of changes made to the list.