Understanding your chronic benefits
As the new year begins, the Council for Medical Schemes (CMS) would like to help you understand your rights and responsibilities as a medical scheme member so you can manage your health with confidence.
One of the key benefits every medical scheme member should know about is chronic benefits. These benefits apply when your doctor prescribes ongoing treatment for a long-term condition, and understanding them can help manage healthcare costs.
Here is a simple guide to what chronic benefits include and how they work.
What Are Chronic Benefits?
By law, all medical schemes must cover certain chronic conditions under the Prescribed Minimum Benefits (PMBs). PMBs are the minimum health services that every medical scheme must pay for, regardless of the option you belong to.
This includes:
- Diagnosis, treatment and ongoing care for chronic conditions.
- Prescribed medication, consultations and required tests related to those conditions.
Which conditions are covered?
The conditions that have been included in PMBs are the most common, serious, and long-term conditions where treatment can significantly improve quality of life.
| Chronic Conditions Covered as Prescribed Minimum Benefits (PMBs) | ||
| Addison’s disease | Crohn’s disease | Hyperlipidaemia |
| Asthma | Diabetes insipidus | Hypertension |
| Bipolar mood disorder* | Diabetes mellitus (Types 1 & 2) | Hypothyroidism |
| Bronchiectasis | Dysrhythmias | Multiple sclerosis |
| Cardiac failure | Epilepsy | Parkinson’s disease |
| Cardiomyopathy | Glaucoma | Rheumatoid arthritis |
| Chronic obstructive pulmonary disease (COPD) | Haemophilia | Schizophrenia |
| Chronic renal disease | Coronary artery disease | Systemic lupus erythematosus |
| Ulcerative colitis | ||
* Bipolar mood disorder may only be covered once treatment algorithms have been developed.
How do chronic benefits work?
You need to use the right providers
Your scheme may have Designated Service Providers (DSPs), which are doctors, pharmacies or hospitals you should use for PMB conditions. If you choose a non-designated provider without permission, you might pay extra.
If you need urgent care and cannot access a DSP, you will be regarded as having obtained the service involuntarily, and the scheme will still have to pay.
Scheme rules and formularies
Most schemes use a formulary, which is a list of approved medicines for chronic conditions. If you choose medicine outside the formulary, you may need to pay a co-payment.
No use of savings for PMBs
Your scheme may not require you to use your medical savings account or charge co-payments for PMB chronic benefits.
Important member tips
- Register your chronic condition with your medical scheme to access benefits.
- Always check which providers and pharmacies your scheme has designated.
- Keep records of doctor visits, scripts and authorisations for faster processing.
- If you disagree with a scheme decision, ask for an explanation or lodge an appeal. If you are still not satisfied, you may submit a complaint to the CMS.
Learn more about chronic benefits here.
