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The Regulations to the Medical Schemes Act in Annexure A provide a long list of conditions identified as Prescribed Minimum Benefits. The list is in the form of Diagnosis and Treatment Pairs (DTPs).
A DTP links a specific diagnosis to a treatment and therefore broadly indicates how each of the approximately 270 PMB conditions should be treated. The treatment and care of PMB conditions should be based on healthcare that has proven to work best, taking affordability into consideration. Should there be a disagreement about the treatment of a specific case, the standards (also called practice and protocols) in force in the public sector will be applied.
The treatment and care of some of the conditions included in the DTP may include chronic medicine, e.g. HIV-infection and menopausal management. In these cases, the public sector protocols will also apply to the chronic medication.
Here is an example of a DTP as it appears in the Medical Schemes Act:
| Code | Diagnosis | Treatment |
| 109A | Vertebral dislocations/fractures, open or closed with injury to spinal cord | Repair/reconstruction; medical management; inpatient rehabilitation up to two months |
The 270 conditions that qualify for PMB cover are diagnosis-specific and include a range of ailments that can be divided into 15 broad categories:
| PMB category | Example |
| Brain and nervous system | Stroke |
| Eye | Glaucoma |
| Ear, nose and throat | Cancer of oral cavity, pharynx, nose, ear and larynx |
| Respiratory system | Pneumonia |
| Heart and vasculature (blood vessels) | Heart attacks |
| Gastro-intestinal system | Appendicitis |
| Liver, pancreas and spleen | Gallstones with cholecystisis |
| Musculoskeletal system (muscles and bones); Trauma NOS | Fracture of the hip |
| Skin and breast | Treatable breast cancer |
| Endocrine, metabolic and nutritional | Disorders of the parathyroid gland |
| Urinary and male gential system | End-stage kidney disease |
| Female reproductve system | Cancer of the cervix, ovaries and uterus |
| Pregnancy and childbirth | Antenatal and obstetric care requiring hospitalisation, including delivery |
| Haematological, infectious and miscellanous systemic conditions | HIV/Aids and TB |
| Mental illness | Schizophrenia |
| Chronic conditions | Asthma, diabetes, epilepsy, Asthma, diabetes, epilepsy, hypothyroidism, schizophrenia, glaucoma, hypertension |
No exclusions
Medical schemes often have a list of conditions – such as cosmetic surgery – for which they will not pay, or circumstances – such as travel costs and examinations for insurance purposes – under which a member has no cover. These are called exclusions. Exclusions, however, do not apply to PMBs. If you contract septicaemia after cosmetic surgery, for example, your scheme has to provide healthcare cover for the septicaemia part because septicaemia is a PMB. (Cosmetic surgery remains exclusion.) PMBs are concerned about the diagnosis; it doesn’t matter how you got the condition.
(Information from the Council for Medical Schemes)
