Prescribed Minimum Benefits (PMBs) explained

PMBs are made up of three parts:

1. Diagnosis and treatment pairs (DTPs). A defined list of 271 conditions, each paired with the treatment the law says must be funded. The list includes many cancers, major surgeries and serious illnesses.
2. The Chronic Disease List (CDL). Long-term conditions such as asthma, diabetes, hypertension, epilepsy and HIV. See chronic disease benefits for how to register.
3. Emergency medical conditions. The Regulations define this as the sudden and unexpected onset of a health condition that needs immediate medical or surgical treatment, where failing to treat it would seriously impair bodily functions, cause serious dysfunction of an organ, or put your life in serious jeopardy.

PMBs are about the diagnosis, not the price of your plan. A basic hospital plan and the most expensive comprehensive plan must both pay them.

A note on the chronic count. The CMS PMB page says 26 chronic conditions. A CMS presentation dated 17 August 2026 says 27. The Regulations name 25 conditions in their annexure. The difference is probably in how HIV and later additions are counted, so check the current Chronic Disease List for your condition rather than relying on the number.

The Regulations say a scheme must pay PMB costs in full, without co-payment or deductibles. They also allow the scheme to manage how you receive that care:

• A designated service provider (DSP). The scheme can require you to use the provider it has chosen for the condition. If you voluntarily use someone else, the scheme's rules can charge a co-payment. The CMS says this could be a percentage or the difference between the DSP's tariff and what your provider charged. See designated service providers.
• Protocols, formularies and authorisation. The scheme can use pre-authorisation, treatment protocols and formularies for PMBs. A refused non-formulary drug can attract a co-payment. See pre-authorisation.

If you follow the scheme's process, PMB care is paid in full. If you do not, you may pay part of it yourself.

No co-payment applies if you obtained the service involuntarily from a non-DSP. The Regulations treat use as involuntary when:

• The DSP could not provide the service, or would not provide it without unreasonable delay.
• Immediate treatment for a PMB condition was needed in circumstances or at a place that reasonably stopped you from reaching a DSP.
• There was no DSP within reasonable proximity of your home or place of work.

The CMS adds that where a DSP cannot accommodate or treat a member, the scheme remains liable for all the costs of treating the PMB condition at a non-DSP. Keep evidence of why the DSP could not be used: dates, referral letters and the name of who turned you away.

A scheme may not stop a provider from starting appropriate treatment for an emergency medical condition before authorisation is received. The CMS states it plainly: in an emergency or accident you may go to the nearest healthcare facility, even if it is not a DSP, and your scheme has to cover the costs.

In practice, get treated first and tell the scheme afterwards. Your scheme's rules set the window for notifying it. See emergency and ambulance cover for what to do on the day.

Exclusions do not apply to PMBs. The CMS gives this example: if you get septicaemia after cosmetic surgery, the scheme must fund the septicaemia, because septicaemia is a PMB, even though the cosmetic surgery itself is excluded.

Hospital plans still cover PMBs. This includes PMB chronic conditions, which is why a hospital plan is not a gap in the safety net. See hospital plans explained.

Waiting periods. For a new member with a break in cover of under 90 days, the Act bars waiting periods on PMB treatment. A person who has had no scheme cover for at least 90 days can face up to a 3-month general and a 12-month condition-specific waiting period. Confirm with the scheme how these apply to your condition. See waiting periods and exclusions.

The Medical Schemes Act requires the PMBs to be reviewed periodically. In 2026 the CMS is working on a primary healthcare (PHC) service benefits package, and a future base benefits package that would combine core PHC, wider PHC and complementary PMBs. A previous review submitted to the Minister was not approved because it lacked a primary healthcare component.

Circular 26 of 2026, dated 14 September 2026, asked schemes for membership and claims data by 15 October 2026 so the CMS can update the costing of the proposed package. The CMS Registrar has also said the aim should not be a smaller PMB package designed mainly to make entry-level products cheaper.

As of 29 September 2026 we found no change to the PMB list, the DTPs or the Chronic Disease List published in the Gazette. The PHC package is a proposal still being costed. Your PMB rights today are the existing ones.

1. Check that the claim really is a PMB: ask your doctor for the diagnosis code and the PMB status.
2. Ask the scheme in writing to review the decision, quoting the diagnosis. Use our PMB application letter or the appeal a rejected claim letter.
3. Use the scheme's internal dispute process and keep the replies.
4. If it is still not resolved, complain to the CMS. The CMS complaints service is free to use. See how to complain to the CMS.

Keep your clinical reports, account statements and correspondence. They are the evidence.