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What is a PMB Disease?

A Prescribed Minimum Benefit (PMB) is 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. Therefore the payment for a PMB should occur whether you have a hospital plan or a top-level full plan.

PMB’s are a feature of the Medical Schemes Act, 131 of 1998, in terms of which medical schemes have to cover the costs related to the diagnosis, treatment, and care of:

  • any emergency medical condition;
  • a limited set of 270 medical conditions (defined in the Diagnosis Treatment Pairs);
  • 25 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 a diagnosis-based. Once the diagnosis has been made, the appropriate treatment and care are decided upon as well as where the patient should receive the treatment (at a hospital, as an outpatient or at a doctor’s rooms).

There are a few general rules that govern all PMB diseases. All Medical Schemes need to adhere to these rules.

  • General rules for the payment of PMB’s:
  • Costs related to diagnosis, treatment, and care of PMB’s are not allowed to be passed through your medical savings account or day to day expense plans.
  • The medical schemes are allowed to stipulate Designated Service Providers (DSP) but they have to be within a reasonable distance from your work and home.
  • Treatment at a DSP will be covered in full by the medical scheme under the PMB conditions when delivered according to scheme protocols and procedures.
  • Medical Schemes cannot charge a co-payment or levy for the treatment of a PMB if you have followed the schemes protocols.

It is the responsibility of each member of a Medical Scheme to empower themselves with knowledge and to know their rights.