Emergency
Any emergency medical condition — nearest facility covered.
Prescribed Minimum Benefits (PMBs)
Prescribed Minimum Benefits (PMBs) are defined benefits to ensure that all medical scheme members have access to minimum health services." />
CMS page cached 2026-09-05 · Live CMS page →
DTP conditions
271 diagnosis–treatment pairs in Medical Schemes Act Annexure A.
CDL chronic disease
26 listed chronic diseases with algorithm minimum standards.
PMB eligibility uses a diagnosis-based approach — symptoms determine the PMB, not how the condition was contracted.
PMB detail sections
What are PMBs?
Prescribed Minimum Benefits (PMBs) are defined benefits ensuring all medical scheme members can access minimum health services regardless of benefit option. Schemes must cover diagnosis, treatment, and care for emergencies, ~271 DTP conditions, and 26 CDL chronic diseases.
PMB objectives
Continuous healthcare even when annual benefits are exhausted; correct payer for PMB treatment (including state hospital care); minimum care regardless of age or option; and sustainable scheme finances through better chronic disease management.
Diagnosis Treatment Pairs (DTPs)
Annexure A to the Medical Schemes Act lists diagnosis–treatment pairs linking a diagnosis to appropriate treatment. Care should follow evidence-based public-sector protocols where schemes disagree. Some DTPs include chronic medicine (e.g. HIV, menopause management).
Chronic Disease List (CDL)
26 chronic conditions with mandated medication, consultations, and tests. Treatment algorithms published in the Government Gazette are minimum standards — scheme cover may not be inferior. Schemes may use protocols, formularies, and Designated Service Providers (DSPs).
Emergency conditions
Sudden, unexpected onset requiring immediate treatment or operation — risk of death, organ damage, or lasting disability without care. Schemes must approve suspected PMB emergencies even before final diagnosis; confirmation may be requested later. Nearest facility is covered in emergencies.
Designated Service Providers
Scheme-first-choice providers for PMB conditions. Non-DSP use may trigger co-payments unless no reasonable DSP exists near home or work. DSPs must deliver without unreasonable delay; if unable, the scheme remains liable at a non-DSP.
Claim context
PMB cover is a medical scheme entitlement under the Medical Schemes Act — separate from income-protection or group disability policy tests (own occupation, waiting periods, exclusions). When a condition appears on the CDL or DTP list, document:
- Scheme PMB approval and treating plan (for healthcare funding disputes)
- Functional limits and material duties (for IP / GIP incapacity claims)
- Clinical Atlas diagnoses and medications (cross-linked from CDL pages)