prescribed minimum benefits

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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
  • 26 chronic conditions defined in the Chronic Disease List (CDL).

PMB Conditions

The 270 conditions are listed in Annexture A of the Medical Schemes Act, which is available on the website of the Council for Medical Schemes at www.medicalscheme.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 26 chronic conditions.

This list is referred to as the prescribed minimum benefits “Chronic Disease List” (CDL).

These conditions are covered in full in terms of the Scheme rules if services are rendered according to the Scheme’s benefits, treatment plans and protocols, CDL medication lists, and claimed with the correct diagnostic (ICD-10) codes.

These conditions are covered on all Profmed’s options, but benefits will be more or less restrictive depending on the option the member has chosen.

Addison’s Disease Epilepsy
Asthma Glaucoma
Bipolar Mood Disorder Haemophilia
Bronchiectasis HIV/AIDS
Cardiac Failure Hyperlipidaemia
Cardiomyopathy Disease Hypertension
Chronic Obstructive Pulmonary Disorder Hypothyroidism
Chronic Renal Disease Multiple Sclerosis
Coronary Artery Disease Parkinson’s Disease
Chrohn’s Disease Rheumatoid Arthritis
Diabetes Insipidus Schizophrenia
Diabetes Mellitus Types 1 & 2 Systemic Lupus Erythematosus
Dysrhythmias Ulcerative Colitis