Prescribed Minimum Benefits and the Chronic Disease List: what every medical aid option must pay

By Tegan Botha, Medaid Quote.

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Prescribed Minimum Benefits, usually called PMBs, are the minimum the law requires every medical aid option to pay for, whatever it costs. This guide sets out what that floor includes, the conditions a scheme may attach to it, and where it stops, as read in Council for Medical Schemes (CMS) sources on 29 October 2026.

What are Prescribed Minimum Benefits?

Section 29(1)(o) of the Medical Schemes Act 131 of 1998 requires the rules of every scheme to provide for the scope and level of minimum benefits that are to be available to beneficiaries as may be prescribed. Regulation 7 of the General Regulations then defines Prescribed Minimum Benefits as the diagnosis, treatment and care costs of two things:

• the Diagnosis and Treatment Pairs listed in Annexure A to the Regulations, subject to any limitations specified there; and
• any emergency medical condition.

A Diagnosis and Treatment Pair links a diagnosis to the treatment a scheme must fund. The annexure does not state a total. The CMS PMB page, read on 29 October 2026, puts the number at 271 conditions.

Regulation 7 defines an emergency medical condition as the sudden and, at the time, unexpected onset of a health condition that requires immediate medical or surgical treatment, where failing to treat it would seriously impair bodily functions, cause serious dysfunction of a bodily organ or part, or place the person in serious jeopardy.

Which chronic conditions are on the list?

The Chronic Disease List sits at the end of Annexure A. For each condition, the treatment a scheme must cover is diagnosis, medical management and medication, to the extent provided for in a therapeutic algorithm for that condition published by the Minister in the Government Gazette.

A condition not on this list can still be a PMB if it appears elsewhere in Annexure A or arises as an emergency. Anything else is paid only according to the benefits of your option.

When must a scheme pay in full?

Regulation 8(1) says any benefit option offered by a medical scheme must pay in full, without co-payment or the use of deductibles, the diagnosis, treatment and care costs of the Prescribed Minimum Benefit conditions. In its guidance on 2027 benefits, Circular 20 of 2026 (31 July 2026), the CMS told schemes that where rules impose monetary limits, they must state that the limits do not apply to PMBs and that PMBs are paid in full when a designated service provider is used.

That last phrase matters. A designated service provider, or DSP, is a provider or group of providers a scheme has chosen to deliver PMB care to its members (Regulation 7). Under Regulation 8(2), scheme rules may say that PMBs are paid in full only at the DSP, and may set a co-payment or deductible if you go elsewhere by choice.

No co-payment may be charged if you used another provider involuntarily. Regulation 8(3) treats it as involuntary if:

• the service was not available from the DSP, or would not be provided without unreasonable delay;
• you needed immediate treatment in circumstances or at a place that reasonably prevented you from reaching the DSP; or
• there was no DSP within reasonable distance of your home or ordinary place of business.

Regulation 8(6) adds that a scheme may not stop a provider from starting appropriate treatment for an emergency medical condition before authorisation is received.

Can a scheme control how a PMB condition is treated?

Yes, within limits. Regulation 8(4) allows pre-authorisation, treatment protocols and formularies (lists of approved medicines). Regulations 15H and 15I require protocols and formularies to be evidence based and to be given to members on request.

The limits run both ways:

• If a formulary medicine is clinically appropriate and effective for you, and you knowingly decline it for another medicine, the scheme may charge a co-payment (Regulation 8(5)).
• If a formulary medicine has been ineffective, or causes or would cause an adverse reaction, the scheme must provide for appropriate substitution without penalty to you (Regulation 15I(c)). Regulation 15H(c) sets the same rule for a protocol that has been ineffective or would cause harm.

Can PMB costs come out of your medical savings account?

No. Regulation 10(6) says that funds in a medical savings account shall not be used to pay for the costs of a prescribed minimum benefit. In a statement dated 19 October 2026, the CMS said a full bench of the High Court held in KeyHealth Medical Scheme v Ngoepe NO and Others (2022) that a scheme must pay PMBs from its risk pool and may not use savings accounts to avoid that obligation.

Where does the PMB guarantee stop?

PMBs are a floor, not a full benefit design. When you compare options, both sides of the trade off are real:

• A lower priced option, such as a hospital plan, still carries the full PMB obligation, including Chronic Disease List medication within the therapeutic algorithms.
• The floor does not cover conditions outside Annexure A, care beyond what the algorithm or Diagnosis and Treatment Pair provides, or the cost of choosing a non DSP provider. A richer option pays more of that, at a higher contribution.
• DSP networks differ between options. A narrow network can cost you co-payments if it does not suit where you live or which doctors you use.
• If you join with no medical scheme cover in the 90 days before you apply, section 29A(1) of the Act allows a scheme to impose waiting periods without the PMB exception that applies to people with recent cover.

The package itself is under review. CMS Circular 22 of 2026 (20 August 2026) says a revised draft PMB package was not approved by the Minister because it lacked primary health care benefits, and that review work is now focused on a primary health care service package. No change to Annexure A had been gazetted in the consolidated text read on 29 October 2026. Our medical aid overview explains how option types differ in price and cover.

How to check this yourself

1. Read Regulations 7, 8, 10 and 15H to 15I, and Annexure A, in the consolidated Medical Schemes Act and Regulations published by the Council for Medical Schemes.
2. Check the Council for Medical Schemes PMB page for its plain language summary and the list of chronic conditions.
3. Ask the scheme in writing who its designated service providers are for your condition on that option, and what co-payment applies elsewhere.
4. If you have a listed chronic condition, ask for the formulary and the process to register the condition, and keep the reference number.
5. If a PMB claim is short paid, complain to the scheme first. The CMS complaints procedure says you must exhaust the internal dispute process of the scheme before lodging a complaint, and must include proof of that escalation.

For more plain language explainers, see our medical aid guides.

Frequently asked questions

Does a hospital plan have to pay for chronic medication?

For conditions on the Chronic Disease List, yes. Regulation 8(1) applies to any benefit option, so a hospital plan must fund medication for those conditions to the extent of the therapeutic algorithm, subject to the DSP and formulary rules of the scheme. Other chronic medication depends on the benefits of the option.

Can my scheme refuse a PMB claim because my annual limit is used up?

Not for the PMB part of the claim. CMS Circular 20 of 2026 requires scheme rules with monetary limits to state that those limits do not apply to PMBs, which are paid in full at the DSP.

Who decides whether something was an emergency?

The test is the Regulation 7 definition: a sudden, unexpected onset needing immediate treatment to avoid serious impairment, serious organ dysfunction or serious jeopardy to life. Disputes go to the scheme first, then the CMS.

Do I need to register a chronic condition with my scheme?

Schemes may require pre-authorisation and may use protocols and formularies (Regulation 8(4)). Ask your scheme whether it requires registration or pre-authorisation for your condition, as the process is set by each scheme.

How long do I have to complain to the CMS?

The CMS complaints page, read on 29 October 2026, asks that complaints preferably be lodged within three years. It gives an overall turnaround time of 120 calendar days from receipt of the response from the scheme and all supporting documents.

If you would like quotes compared across several medical schemes, you can request a free medical aid quote.

Last reviewed: 29 October 2026. Sources: Medical Schemes Act 131 of 1998, sections 29(1)(o) and 29A; General Regulations, Regulations 7, 8, 10(6), 15H and 15I and Annexure A (as substituted or inserted by GN R1360 of 2002, Regulation 8 and the Chronic Disease List with effect from 1 January 2004), CMS consolidated text; CMS PMB page; CMS Circulars 20 of 2026 (31 July 2026) and 22 of 2026 (20 August 2026); CMS statement of 19 October 2026; CMS complaints procedure page. All read 29 October 2026.