Craig Comrie | CEO | Profmed | mail me |
If you’re a member of a medical scheme, you should understand Prescribed Minimum Benefits (PMBs). By law, all medical schemes must offer these benefits to every member. This requirement applies regardless of the scheme you choose.
PMBs guarantee access and cover for a minimum, defined list of healthcare benefits. In effect, they represent the bare minimum of PMB protection in the private healthcare system.
The intention behind PMBs is straightforward. They aim to ensure that all medical scheme members in South Africa can access essential treatment for certain pre-determined conditions. In theory, PMBs act as a safety net. They guarantee a minimum level of care for serious illnesses such as cancer. On paper, the bare minimum of PMB sounds reassuring.
Rising costs and unintended consequences
In practice, however, PMBs come at a growing cost. Healthcare actuaries estimate that this defined basket of benefits costs close to R2,000 per beneficiary per month. Because medical schemes must legally provide PMBs, these costs feed directly into higher premiums. As a result, affordability becomes a challenge for many households.
PMBs aim to protect members. At the same time, they should support access to private healthcare. This tension sits at the heart of debates around Low-Cost Benefit Options (LCBOs). These products, such as health insurance offerings, provide cover well below the bare minimum of PMB. They are often viewed as more affordable than traditional medical schemes. However, for schemes to compete, the regulator must grant exemptions from PMB requirements.
Despite limited concessions around PMBs, members should recognise an important distinction. PMBs provide significantly stronger protection than most health insurance products. Even the bare minimum of PMB generally offers better coverage than non-scheme alternatives.
What PMBs do – and do not – cover
Many members mistakenly believe PMBs guarantee full or maximum cover. This assumption creates confusion. Even when a condition qualifies as a PMB, schemes do not necessarily cover all treatment. PMBs focus on basic, life-saving care. They do not promise the best or most advanced interventions. In other words, they define the bare minimum of PMB care.
Regulations rely on treatment algorithms. These algorithms determine whether a condition requires surgical or medical intervention. They also define the level of care a scheme must fund. For example, a cancer diagnosis does not automatically entitle a patient to every available treatment. That expectation, while understandable, is incorrect.
Cancer treatment illustrates this limitation clearly. Many cancer therapies rely on biologic drugs. These treatments are costly. However, biologics do not fall within the bare minimum of PMB care. A patient may qualify for surgery and standard medication, but not for biologics that could significantly improve outcomes. In such cases, a more comprehensive medical scheme option may cover some biologics. Coverage depends entirely on the benefits linked to that option.
Patients often view biologics as essential. Oncologists may also recommend them as the most effective way to control cancer. Despite this, PMBs exclude biologics because of their cost. This gap explains why debates about minimum versus maximum benefit remain so difficult and emotionally charged.
Navigating complexity and the need for reform
To manage these challenges, schemes rely on specialised support. Oncology-trained nurses often engage directly with oncologists. They help members structure treatment plans that balance PMB entitlements with additional benefits and costs. This healthcare coaching provides vital guidance for members facing serious illness. It helps them navigate the limits of the bare minimum of PMB while planning responsibly.
At the same time, the PMB framework itself needs urgent review. The current list of benefits is more than 20 years old. It no longer reflects modern healthcare realities. Regulators have acknowledged this concern in recent years. Within the context of the National Health Insurance agenda, policymakers are debating the introduction of a primary healthcare package as part of PMBs.
Currently, PMBs do not include primary or preventative care. They apply only after diagnosis. There is ongoing discussion about incorporating preventative and primary care benefits into PMBs. Medical schemes generally support this direction, provided costs remain carefully managed.
As a scheme, we have applied to the regulator for approval to offer low-cost benefit options. These options aim to improve affordability, particularly for graduates starting businesses who worry about premium costs. An effective LCBO would exempt members from PMBs. It would still provide cover aligned with their needs and financial realities, without defaulting to the bare minimum of PMB.
In conclusion
PMBs play an important role. They exist to protect members. However, in their current form, they can also make healthcare less accessible and more expensive. They frequently create confusion, especially around expectations for treatment and coverage.
Even with a serious diagnosis, members must understand what their scheme will and will not fund. Schemes assess individual cases carefully. Ongoing engagement and support, therefore, remain essential.
PMBs were designed to guarantee a minimum standard of care. Today, they also drive costs upward while limiting access to private healthcare. Every medical scheme member should understand the scope and limits of PMBs. At the same time, the system requires urgent reform to keep pace with modern medicine.
Ultimately, PMBs should serve the people they were meant to protect. Until reform occurs, careful planning, clear communication and sustained support remain critical if South Africa is to extract real value from the PMB system.
