Category Healthcare
SUB CATEGORIES General  |  HIV |  Medical Schemes | 

Understanding Prescribed Minimum Benefits

11 February 2019 Selfmed Medical Scheme

Healthcare in South Africa is extremely expensive. The cost of medical consultations, procedures and medications continue to rise annually. Without the assistance of a quality medical aid scheme, you would be left to fend for yourself when it comes to your health and the wellbeing of your family.

Selfmed Medical Scheme offers our clients a simplistic range of products and medical aid options to suit your essential healthcare needs. Being a part of a medical aid will also grant you access to a number of added benefits which can make all the difference should you, or your dependants, face serious illnesses of many kinds.

As mandated by the Medical Schemes Act, Selfmed adheres to a list of Prescribed Minimum Benefits (PMB) on offer to all of our members. The PMB refer to a list of medical and chronic conditions for which you will automatically qualify for benefits from your medical aid, as prescribed by the Department of Health.

The list includes 270 medical conditions and 25 chronic conditions for which medical schemes are compelled by law to grant benefits to its members. That is, you will receive benefits towards the cost of diagnosis, treatment and care for the PMB conditions listed, no matter what medical aid plan you are on.

In the unfortunate event that you are faced with one of the serious illnesses listed to receive PMB, you can rest assured that you will be well taken care of.

Even if you are only subscribed to receive in-hospital cover through Selfmed, we will still ensure that you receive all the added benefits of PMB while in hospital, as stipulated by law. PMB are a guarantee that you will receive on-going support and quality, affordable healthcare for your listed condition. In some cases the PMB may also include chronic medication.

The 270 medical conditions are diagnosis-specific and fall into 15 subdivided categories such as heart and vasculature; brain and nervous system; or ear, nose and throat. The PMB list is in the form of Diagnosis and Treatment Pairs (DTPs). A DTP links a particular diagnosis to a recommended treatment – one that has been known to offer the best results, is medically approved and affordable.

Besides the above conditions, a further 25 chronic conditions are covered. Chronic illnesses eligible for cover range from epilepsy and asthma to Crohn’s disease and Diabetes (types 1 and 2). For some conditions, prescribed algorithms are used to determine the value of PMB coverage per patient.

It is important to read through the conditions of your medical aid plan and understand how the cover, pre-authorisation and claims process work. In most instances PMB will also require that you make use of designated service providers in order to receive full cover.

It is wise to plan ahead and take control of your future wellbeing by investing in a quality medical aid scheme that will help lighten your burden when it comes to your healthcare. As a member of Selfmed, you can rest assured that in the case of any of the PMB listed conditions, you will always receive the Prescribed Minimum Benefits that you are justly entitled to – and this fact alone should give you peace of mind that you will be looked after in times of illness, without the added worry of financial pressure.


Quick Polls


With regards to the COFI Bill, do you believe lumping the health and finance sector in the same basket will sustain the financial sector?


Yes, it forms part of the FSCA’s mandate to protect and maintain the sustainability of the financial sector, and to legislate fairness and make it the law
No, the products are different therefore the health sector should not have to be subjected to similar conduct requirements
This will cause problems. More consultations should be conducted before the final version of the COFI Bill is sent to Parliament for promulgation
A E fanews magazine
FAnews April 2019 Get the latest issue of FAnews

This month's headlines

Differences aside… in the name of fairness
Advice… now more important than ever
COFI… is this a reason to be positive?
Cyber cover: One size does not fit all
The need for member education
Subscribe now