Failing to use a designated service provider for a prescribed minimum benefits hospital stay can leave a medical aid member paying up to 40% of a non-contracted specialist’s bill. (Image: iStock) 
For many South Africans using medical aid schemes, the real test of their cover often comes when they least expect it — at a hospital desk or pharmacy till, faced with a bill they thought would be paid in full. That’s often when they encounter the cornerstone of private healthcare: prescribed minimum benefits (PMBs).
They are the legally defined services every medical aid scheme must cover, regardless of one’s plan type or savings balance.
As financial planner Kobus Kuhn explains, PMBs exist “to level the playing field” and ensure members aren’t ruined by essential or emergency care. “They exist so no one ends up bankrupt because they got sick at the wrong time,” he says.
What PMBs cover
Under South Africa’s Medical Schemes Act, PMBs include 271 conditions and 26 chronic diseases, from hypertension and diabetes to HIV and tuberculosis. They also cover emergencies, where treatment can’t be delayed.
Dr Ron Whelan, chief executive of Discovery Health, notes that outside the PMB framework, each scheme defines its own benefits and decides which additional procedures, treatments or medications to fund.
The obligation to fund PMB treatment in full, even when one’s savings are depleted, is unconditional.
However, schemes may enforce cost-saving measures by requiring members to use specific doctors, hospitals or pharmacies, known as designated service providers. That’s often where confusion — and extra cost — begins.
Where members get caught out
PMBs should protect members from surprise expenses. In practice, many pay more than they should because of technicalities. For example, using a non-designated service provider or failing to register a chronic condition can lead to copayments or denied claims.
Pre-authorisation and correct ICD-10 coding are also key. Without them, claims can be declined even if the condition qualifies as a PMB.
The cost of a mistake can be steep. Failing to use a designated service provider for a PMB hospital stay can leave a member paying up to 40% of a non-contracted specialist’s bill — easily running into tens of thousands of rand.
Out-of-hospital care can be just as confusing. Some schemes deduct these costs from day-to-day benefits before shifting them to risk cover.
“It’s not that the cover isn’t there,” Kuhn explains. “People just don’t know how to access it — and that lack of awareness leads to unnecessary costs.”
Your PMB member checklist
Despite their flaws, PMBs remain one of the strongest consumer protections in healthcare in South Africa. They are the difference between a safety net and the illusion of cover. But that protection works only if members know how to use it.
Register early: If you’re diagnosed with a chronic illness, register it promptly with your scheme.
Confirm your provider: Always check whether your doctor or hospital is a designated service provider.
Keep documentation: Save pre-authorisations, correspondence and letters declining claims for reference.
Know your codes: Ensure your doctor uses the correct ICD-10 codes on medical claims.
Ask in writing: If your claim is rejected, request a written explanation from your scheme — and escalate your query to the Council for Medical Schemes if necessary.
The mental health gap
PMBs remain a work in progress, especially in mental health, where the covered conditions have barely changed in two decades. Psychologist Gerrit Nel notes that only a handful of psychiatric illnesses, such as bipolar disorder and schizophrenia, qualify. Common but debilitating conditions like PTSD, depression and anxiety are excluded.
“It’s a system that still medicalises distress,” Nel says. “We treat only the most severe illnesses while overlooking the need for therapy and recovery.”
This gap is glaring in a country grappling with trauma and gender-based violence. It leaves many patients without access to vital psychological care.
“In South Africa, trauma is almost universal,” Nel says. “PMBs should reflect that reality.”
For many, the right to equitable healthcare feels incomplete without reform. Understanding PMBs can mean the difference between financial strain and security. As Kuhn puts it: “Your medical aid is a contract — and PMBs are the part written in your favour.”
Your health is your right — and your scheme is legally bound to protect it. DM
Where to learn more: For the official PMB list, complaint forms and member guides, visit the Council for Medical Schemes (CMS) at www.medicalschemes.co.za.
For advice or complaints about medical aid scheme compliance, contact the CMS call centre on 0861 123 267.
This story first appeared in our weekly Daily Maverick 168 newspaper, which is available countrywide for R35.
