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Medical aid

Prescribed minimum benefits

Schemes must cover a defined set of emergencies, chronic conditions and hospital care. That is not a promise of any hospital or any specialist rate.

Reviewed 29 October 2026 by the WiT Money editorial team. This is general information, not a recommendation from a named adviser.

Key points

  • Prescribed minimum benefits are a floor in the Medical Schemes Act, not a blank cheque.
  • Using a designated service provider matters. Going outside the network can leave you with a co-payment.
  • The chronic disease list is a list. A condition that is not on it is not automatically a PMB.

The regulations set out what a scheme must pay for prescribed minimum benefits, including diagnosis, treatment and care. In an emergency the scheme must cover the immediate care. For other PMB care, the scheme can require you to use designated service providers. If you use someone else without a valid reason, the scheme can expect you to pay the difference.

Chronic medicine is paid according to the scheme's formulary and the chronic disease list. A brand your doctor prefers may not be the one the scheme funds in full. Ask the scheme, not the pharmacy poster, whether the item is covered on your option.

Networks and co-payments

A hospital network is a list of hospitals the option prefers. Using another hospital can mean a co-payment even when the admission is necessary. Co-payments for procedures such as scopes are written in the rules. They are not a surprise if you read the option guide before the admission.

Complaints

Dispute the claim with the scheme first, in writing, and keep the reference. The Council for Medical Schemes deals with scheme complaints. It does not deal with a health-insurance policy. That complaint goes through the insurance channels.

Questions readers ask

Does a PMB mean I can see any specialist?

No. Designated providers and scheme tariffs still apply. A PMB is a benefit category, not a freedom to ignore the network.

Related

Sources

Page updated 29 October 2026. A source date is the day WiT Money checked that page, not a promise the institution has not changed it since.