According to the Medical Schemes Act, Prescribed Minimum Benefits (PMBs) are a set of defined benefits that all registered medical schemes in South Africa must provide for all their members no matter which plan type they are on. PMBs ensure that all medical scheme members have access to a defined list of conditions for continual care to improve their health.
UKZN Medical Scheme is structured so that cover is maximised. Your health plan benefits offer more cover than just the minimum requirements for PMB. When in doubt, consult your UKZN Medical Scheme Benefit Brochure to see how you are covered.
PMBs are guided by a list of medical conditions as defined in the Medical Schemes Act:
Before you can benefit from PMB treatment, you need to meet certain requirements. These are:
The Scheme has selected specific hospitals and other healthcare service providers as our Designated Service Providers (DSPs) or 'network'. To access the latest UKZN Medical Scheme DSP list of hospitals and other service providers, go to www.discovery.co.za and log in with your username and password. Click on the 'UKZN MS' tab. Look under 'Hospital and doctor visits' and click on 'Find a healthcare professional'.
You must use our DSPs to make sure your PMB claim will be covered in full. In the unlikely event that the Scheme does not have a DSP for your specific healthcare need, please contact our Call Centre at 0860 11 33 22 for assistance to obtain the required approval prior to the treatment.
If you choose not to use DSPs, we pay for PMB medical expenses incurred up to the Scheme Rate. You will be responsible for the balance (also referred to as a co-payment).
Make sure to start your healthcare journey using a DSP healthcare professional who has admitting rights to one of our DSP hospitals in the event that you may require in-hospital treatment. You will be liable for a co-payment, referred to as a 'fixed deductible', for PMB admissions to a non-DSP hospital, irrespective of the healthcare provider being a DSP.
Treatment and care including consultations and investigations or procedures in an emergency/casualty setting not leading to an immediate admission will fund from your day-to-day benefits. If your healthcare provider informs you that the treatment may be regarded PMB level of care, please complete the 'Application for Out-of-Hospital management of a PMB condition' and submit it with the relevant supporting information and documentation applicable to the Scheme for PMB review. To access the 'Application for Out-of-Hospital management of a PMB condition' document go to www.discovery.co.za and log in with your username and password. Click on the 'UKZN MS' tab. Look under 'Scheme Forms' and click on 'Application forms'.
How do I register a Prescribed Minimum Benefit condition?
There are different types of PMB cover. These include cover for:
To apply for out-of-hospital PMBs or cover for a Chronic Disease List (CDL) condition, you must complete the Prescribed Minimum Benefit or a Chronic Illness Benefit application form. Online applications for CDL conditions are also available for your doctor to complete and submit through the Discovery Health ID platform.
We pay for specific healthcare services related to each of your approved conditions. These services include approved treatment, medicine, consultations, blood tests and other defined tests. These are paid from your Prescribed Minimum Benefits and will not affect your day-to-day benefits.
We will pay for treatment or medicines that fall outside the defined benefits and that are not approved from your available day-today benefits, according to the Scheme rules. If your health plan does not cover these expenses, you will have to pay these claims.
The person with the PMB or chronic condition must complete the relevant application form with the help of their healthcare provider. The main member must complete and sign the form if the patient is a minor. Each person with PMB or chronic conditions must register their specific conditions separately. You only have to register once for a chronic condition but mental health conditions such as depression, needs an annual reapplication for PMB cover. If your medicine or other treatment changes, your doctor can let us know about these changes.
For any new conditions, you will have to register each new condition before we will cover the treatment and consultations from your Prescribed Minimum Benefits and not from your day-to-day benefits.
For chronic conditions, your doctor or pharmacist can make changes to your medicine telephonically by calling 0860 11 33 22, by emailing an updated prescription to CIB_APP_FORMS@discovery.co.za. For other PMB conditions, your doctor or pharmacist can make changes to medicine by emailing the updated prescription to PMB_APP_FORMS@discovery.co.za.
When you join the Scheme, you receive a welcome pack which includes high-level communication on PMBs, waiting periods and all plan benefits. Information on PMBs is also provided in the member benefit guides sent to you every year.
Visit www.discovery.co.za or the Discovery app for further information on PMBs.