You hear people talking about prescribed medical benefits. If you are as clueless as me about them, then take a look. Because the question is, are you benefiting from prescribed medical benefits?
Do you know what they are, when to use them, who institutes them, where they can be found, what ones should you have, and why? Then the other important question is, which medical benefits or prescribed medical benefits are important?
At your age or given your health condition, and what happens if something else crops up and you don’t have that prescribed medical benefit?
You know, I for years worked for companies where they provided you with a full medical aid. So when I came off the medical aid, when I no longer worked for a large company, I was suddenly thrust into the nightmare world, much like the Dark Knight enters his nightmare world and has to fight the enemy.
After several years, I still haven’t got around to really know what’s going on with these medical aids and medical insurance.
It’s a Byzantine system, so complicated that nobody knows what it’s about.
I mean, come on, just go ask somebody, do you know your prescribed medical benefits? And they’ll look at you with a blank face.
It’s only those who have worked in the medical profession or on the sidelines of the medical profession that would even know what PMBs are.
So let’s take a look at it and try to see how it can help us.
What Are Prescribed Minimum Benefits (PMBs)?
PMBs are a legally required package of healthcare services that every registered medical scheme in South Africa must cover. They exist so that no matter what plan you’re on, you get access to essential treatment for:
• Any emergency medical condition (car accident, heart attack, severe asthma attack).
• 271 Diagnosis Treatment Pairs (DTPs) — a long list of conditions linked to defined treatments.
• 27 chronic conditions on the Chronic Disease List (CDL), such as diabetes, epilepsy, asthma, high blood pressure, and more.
The key thing to know: PMBs are diagnosis-based. If your doctor submits the correct diagnosis (using ICD-10 codes), the scheme must cover it — even if your plan’s savings or day-to-day benefits are used up.
Who Is Responsible for PMBs?
The Council for Medical Schemes (CMS) enforces PMBs under the Medical Schemes Act (No. 131 of 1998). Their job is to make sure:
• Schemes comply with the law.
• Members get the cover they’re entitled to.
• There’s a safety net against catastrophic health costs.
Where Can You Find the PMB List?
If you want to check what’s covered:
• Visit the CMS official website, which has a PMB portal.
• Look in your scheme’s plan documents — most have a PMB section.
• The full technical list is in Annexure A of the Medical Schemes Act.
Why Do PMBs Exist?
They’re designed to:
• Guarantee care even when your annual benefits run out.
• Stop members from being bankrupted by serious illness.
• Standardise essential healthcare so everyone on medical aid has a basic safety net.
When Do PMBs Really Matter?
PMBs are most important to know about when:
• You’re choosing a plan and want to see what’s “guaranteed.”
• You land in an emergency room.
• You’re diagnosed with a chronic illness (like diabetes or hypertension).
• You’ve run out of day-to-day benefits but still need treatment.
• You’re disputing a rejected claim — knowledge of PMBs gives you grounds to appeal.
Which PMBs Apply to You?
Not all PMBs are equally relevant to everyone. Here’s a snapshot by life stage:
• Children: asthma, epilepsy, congenital disorders.
• Young adults: depression, diabetes, HIV, certain cancers.
• Middle-aged adults: hypertension, heart disease, cancer screenings.
• Elderly: stroke, dementia, arthritis, chronic heart failure.
Practical Tip:
When you see your doctor, make sure they include the correct ICD-10 code on the claim. This is the code schemes use to identify if your treatment qualifies as a PMB. Without it, you could be denied cover that is actually your right.
PMBs won’t solve every headache of navigating the South African medical aid system, but they are a foundation of protection. Too many people don’t even know they exist — and as a result, they don’t insist on the cover they’re legally entitled to.
So, next time you’re paging through your medical aid plan or dealing with a claim, pause and ask: “Is this covered under PMBs?” You might find that the Byzantine world suddenly opens a small, clear doorway to care you didn’t know you already had a right to.
PMB Cheat Sheet — What You Need to Know
• PMBs = Prescribed Minimum Benefits
A legal package of benefits all medical schemes must cover.
• What’s Covered?
• Any emergency medical condition
• 271 Diagnosis Treatment Pairs (DTPs) — specific conditions with defined treatments
• 27 chronic conditions on the Chronic Disease List (CDL) — e.g. diabetes, asthma, hypertension, epilepsy
• Who Oversees PMBs?
• The Council for Medical Schemes (CMS) under the Medical Schemes Act
• Why Do They Exist?
• To guarantee essential care even if your benefits are finished
• To protect you from catastrophic healthcare costs
• When Do PMBs Matter Most?
• During an emergency
• If you’re diagnosed with a chronic illness
• When your plan’s annual savings run out
• If you’re disputing a rejected claim
• Quick Tip: Always ensure your doctor includes the correct ICD-10 code on your claim. This is how schemes identify PMB conditions.
