Dear Business Partner,

In this edition, I will be looking at the Prescribed Minimum Benefits (PMB) – governed by regulations under the Medical Schemes Act (MSA) – and how this correlates with the need for gap cover.

The PMB are defined by pairs of diagnosis and treatment codes, covering around 270 conditions/procedures for mainly in-hospital treatment, plus 27 chronic conditions. The regulations oblige medical schemes to pay the full cost of treatment for PMB, although there are several criteria that need to be fulfilled before they are liable to do so. It is also important to note that not all medical treatment qualifies as PMB.

Over the past decade, the evolving patterns of charges from medical providers and the utilisation of medical services, have had a large impact on consumers. This is because the unavoidable response from medical schemes, in an effort to keep contribution increases as low as possible, has been to effectively reduce cover levels or impose co-payments through benefit design changes.

Obviously, where a medical scheme makes any change to their benefit design it must adhere to the PMB. So, I will take a look at the PMB and their associated rules and discuss why it is important to consider.

When is a PMB a PMB?

The policy principle of the PMB and the regulations is to financially protect members against large out-of-pocket medical costs.

However, to mitigate risks for medical schemes, the regulations obligate members to obtain treatment from one of their medical scheme’s Designated Service Providers (DSP), before PMB treatment costs must be paid in full.

In practice a DSP may not always be readily accessible, so the regulations also stipulate that if a member was compelled, through no fault of their own, to involuntarily obtain the services of a provider that is not a DSP for a PMB condition, then such treatment must still be covered in full by the medical scheme. If the treatment received meets any one of these three criteria, then treatment is deemed to have been obtained involuntarily:

  1. No DSP was available to provide the services, or could only be provided after an unreasonable delay
  2. Immediate treatment was required under circumstances or locations that reasonably precluded the member from obtaining such treatment from a DSP
  3. No DSP was available within a reasonable proximity to the member’s workplace or residence

Lastly, any treatment that is considered an ‘Emergency Condition’ is also a PMB. This is defined as any condition requiring immediate medical treatment that would otherwise cause serious impairment to bodily functions, an organ or body part or place the person’s life in jeopardy.

Below I have put together a simple decision tree to illustrate when a medical scheme is obliged to pay for PMB claims at cost and when it is not:

As can be seen from the above, the circumstances under which a PMB claim must be paid in full by a medical scheme has several caveats. Furthermore, it can sometimes be a grey area as to what qualifies as ‘Obtained Involuntarily’ – as can be seen in bullet points 1, 2 and 3 above, the regulations use terms open to subjective interpretation, eg “unreasonable delay”, “reasonably precluded the member from” and “reasonable proximity”.

In such a situation, a medical scheme may not agree on the qualifying definition, which will leave the member out-of-pocket.

Mitigating financial liability for your clients

In any event, as I mentioned earlier the defined list of PMB does not cover all possible medical treatment – it is a selective list only covering specific treatment types. As an example, certain cancers are PMB but only if it is ‘in-situ’, i.e. it has been detected early and is diagnosed as stage 1. If the cancer has spread (stage 2 or more), the diagnosis no longer qualifies as a PMB.

Clearly members cannot pick and choose the circumstances under which they will need medical care, since illness is unpredictable and varied.

This is why members very often find themselves being liable for substantial shortfalls on specialists’ accounts and having to pay large co-payments upfront when being admitted to hospital, despite the protection that the PMB offer medical scheme members.

The only viable solution is for members to add gap cover to their medical scheme cover – this provides them with a comprehensive financial solution against major medical costs and peace of mind, since they do not need to concern themselves with the above complexity and uncertainty of whether their claim is a PMB or otherwise!

Below, I’ve added to the decision tree graphic to exemplify it – wherever the medical scheme does not cover the claim in full as a PMB, the member can claim the shortfall from their gap cover policy.

The last point to make here is on the benefits and rules of gap cover providers.

Certain gap cover providers reject claims that are coded as PMB, regardless of any other circumstances. This really defeats the objective of having gap cover in the first place, as it can still leave the member out-of-pocket.

It is therefore critical that consumers (and brokers) ensure that their gap cover provider will cover PMB claims since, as we have examined above, medical schemes are not always obligated to cover claims for PMB in full.

I welcome any comments, queries or discussions. Feel free to drop me a note on

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