The Council for Medical Schemes (CMS) is shifting away from condition-specific rules and adopting a service-based Primary Health Care (PHC) package for medical aids.
South Africa’s outdated prescribed minimum benefits (PMBs) system was legally obligated to cover treatments only if a patient’s diagnosis corresponded to a strict list of conditions.
The new approach, proposed by the Council for Medical Schemes (CMS), shifts away from this disease-specific model and instead emphasises the need to cover a wider range of healthcare services.
South Africa’s prescribed minimum benefits (PMBs) system has remained largely unchanged for years, despite notable shifts in healthcare costs, treatment approaches, and disease patterns.
This situation adds extra pressure on medical aid members, who have already been burdened by above-inflation premium increases over the years.
PMBs were established to ensure that medical scheme members can continue to receive treatment for certain serious conditions, even after their regular medical aid benefits have been exhausted.
Legally, PMB regulations require a review at least every two years; however, no major updates have been implemented since 2003.
To address this issue, the CMS has announced that it is shifting away from condition-specific rules and adopting a service-based Primary Health Care (PHC) package.
This new approach aims to rectify regulatory shortcomings, assess cost-effectiveness, align with evolving national health policies, and manage the increasing financial burden on medical schemes and their members.
The CMS highlighted several administrative and historical bottlenecks that have contributed to these extensive delays.
Initially, the Minister of Health rejected a draft of the revised PMB package for failing to include essential primary healthcare benefits.
This rejection forced the CMS to completely refocus its efforts on designing and costing a brand-new PHC framework.
This momentum was further disrupted by COVID-19-related challenges between 2020 and 2022.
Once activities resumed, the Minister of Health directed the CMS and the National Department of Health (NDoH) to align their PHC packages for consistency between private and public healthcare frameworks, which continued through 2024 and 2025.
For the 2026/2027 financial year, the CMS announced that it is concentrating on three main areas as its immediate next steps.
The CMS said it is updating the costing of the newly aligned PHC package. This will involve requesting new claims data from medical schemes to assess affordability and care pathways.
The CMS said it will use this to update its financial models to align with the newly aligned CMS/NDoH package, while analysing affordability and care pathways.
In response to the Competition Commission’s Health Market Inquiry recommendations, they are developing a draft “base benefits package” that integrates core primary care with prioritised catastrophic PMB coverage.
To ensure that patients are not subjected to outdated care standards while these broader changes are being finalised, the CMS is actively drafting ten new PMB Definition Guidelines.
According to the CMS, these guidelines will update standard treatment protocols and essential medicines lists to reflect modern medical advancements.
Katlego Mothudi, managing director of the Board of Healthcare Funders (BHF)
In an interview with The Money Show, Katlego Mothudi, managing director of the Board of Healthcare Funders (BHF), emphasised the need for urgent reform of the healthcare system.
He argued that current regulations are outdated and are contributing to increasing healthcare costs.
Before the implementation of the Prescribed Minimum Benefit (PMB) system, patients could be discharged from the hospital or referred to public healthcare facilities once their insurance coverage was exhausted.
Mothudi noted that the PMB system was intended to be reviewed every two years, as healthcare needs and costs are expected to evolve over time.
However, he pointed out that the last significant changes were made in 2003.
Since the introduction of the PMB system, the cost of providing PMB coverage has risen dramatically.
In 2003, medical schemes allocated approximately 40% of their budgets to PMBs; now, this figure exceeds 60%.
“This means that at the moment, because it establishes the threshold for entry into healthcare funding, you and every beneficiary on the scheme would be liable to about R1,600 per month, per beneficiary,” he said.
“For a family of three, it means you are out of pocket by R4,000, just at the lowest level.”
According to Mothudi, responsibility for reviewing the PMBs rests with both the Department of Health and the Council for Medical Schemes.
He explained that several committees had been established over the past eight years to consider changes, but no major reforms had emerged.
He attributed part of the delay to the long-running uncertainty surrounding the National Health Insurance (NHI) plans.
