Prescribed Minimum Benefits

The Prescribed Minimum Benefits (PMBs) covered by Profmed medical aid scheme are a feature of the Medical Schemes Act, in terms of which medical schemes have to cover the costs related to the diagnosis, treatment and care of:

• any emergency medical condition;
• a list of 270 PMB medical conditions (defined in the Diagnosis Treatment Pairs – DTPs); and
• 28 chronic conditions defined in the Chronic Disease List (CDL).

PMB conditions

The 270 conditions are listed in Annexure A of the Medical Schemes Act, which is available on the website of the Council for Medical Schemes at www.medicalschemes.com. The Act obliged schemes from 1 January 2000 to provide minimum benefits for these conditions.

Chronic Disease List (CDL)

From 1 January 2004 medical aid schemes were obliged to fund the cost of the diagnosis, medical management (consultations and procedures) and medication of a specified list of a further 28 chronic conditions. This list is referred to as the prescribed minimum benefits Chronic Disease List (CDL). These conditions are paid in full provided these services are obtained from the relevant designated service provider (DSP). However, if such services are obtained voluntarily from a provider other than the DSP, the member will be liable for the balance of the account or the balance will be deducted from the relevant day-to-day benefit, subject to available funds. If the service was obtained involuntarily from a provider other than the DSP, the service will be paid in full. All PMB treatments will be subject to the Scheme’s benefit options, treatment plans, formularies and protocols, and must be claimed with the correct diagnostic (ICD-10) codes.

These 28 chronic conditions, listed below, are covered on all Profmed options, but benefits will be more or less restrictive depending on the option the member has chosen: