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Prescribed Minimum Benefits

PMBs were introduced into the Medical Schemes Act to ensure that members of medical schemes would not run out of benefits for certain conditions and find themselves forced to go to state hospitals for treatment. These PMBs cover a wide range of close to 300 conditions, such as meningitis, various cancers, menopausal management, cardiac treatment and many others including medical emergencies.

In order to understand the impact of the legislation changes, a clear understanding of the terminology is required:

Designated service provider (DSP)
This refers to health care provider/s that have been “selected by the scheme to provide its members diagnosis, treatment and care in respect of one or more of the PMB conditions”.

Emergency medical condition
This is a medical condition which is of sudden and unexpected onset that requires immediate medical or surgical treatment. Failure to provide this treatment would result in impairment of bodily functions, serious dysfunction of a bodily organ or part, or would place the person’s life in serious jeopardy.

Prescribed Minimum Benefits (PMB’s)
PMB’s are minimum benefits which by law must be provided to all medical scheme members and include the provision of diagnosis, treatment and care costs for:

* any emergency medical condition
* a range of conditions as specified in Annexure A of the Regulations

to the Medical Schemes Act (No 131 of 1998), subject to limitations specified in Annexure A. Included in this list of conditions is the list of chronic conditions

Why have PMB’s been legislated?

PMB’s were introduced to avoid incidents where individuals lose their medical scheme cover in the event of serious illness and are put at serious financial risk due to unfunded utilization of medical services. They also aim to encourage improved efficiency in the allocation of private and public health care resources.