The Council for Medical Schemes (CMS) has initiated a significant review of Prescribed Minimum Benefits (PMBs) for medical aids in South Africa, a move announced at the end of August. This critical review represents a key moment for healthcare provision in the country. The full overhaul aims to redesign primary healthcare coverage within the nation's medical scheme framework, signaling a substantial shift in how essential health services are structured and delivered. The CMS stated that it had previously requested and received beneficiary membership and claims data from medical schemes to support the initial costing of the proposed primary healthcare (PHC) package. This initial data collection was key for laying the groundwork for the extensive transformation envisioned.
Significant progress has been made in refining the proposed PHC package, aligning service packages, and undertaking further affordability analyses, according to the CMS. The regulator confirmed that updated membership and claims data are now required to ensure the costing accurately reflects current use patterns, healthcare expenditure, and the refined PHC package. This continuous data collection and analysis are vital to ensure the viability and effectiveness of the new system.
Understanding Prescribed Minimum Benefits
South Africa's Prescribed Minimum Benefits (PMBs) represent a defined package of healthcare services that medical aid schemes are legally required to cover for their members. These benefits aim to ensure that individuals have access to essential healthcare, even if their chosen medical aid plan has limited benefits or if they have exhausted their annual limits. The PMB list covers 271 acute and severe medical conditions, ensuring full care for a wide range of health issues. This mandated coverage is a cornerstone of the country's medical aid system, providing a safety net for members facing significant health challenges.
Regulations stipulate that PMB provisions should undergo a review at least every two years. Despite this requirement, the core PMB regulations in South Africa have not been substantially changed since their introduction in 2003. This long period without significant updates precedes the current review by the Council for Medical Schemes, noting the urgent need for modernization. PMBs account for approximately 60% of the billions of rands allocated annually to healthcare benefits within the country's medical scheme sector. This significant proportion shows their critical role in the funding and delivery of healthcare services in South Africa, making any reform impactful across the entire system.
The Shift to Primary Healthcare Package
The cost for medical schemes to cover Prescribed Minimum Benefits (PMBs) can reach R1,600 per member. This substantial cost notes the financial implications of the current system and the potential impact of any changes. The Council for Medical Schemes (CMS) has been working for years to transform the PMB system into a new package centered on primary healthcare services (PHC). This long-term strategic objective aims to reorient healthcare delivery towards more preventative and accessible primary care. The proposed PHC package has undergone refinement through extensive stakeholder consultation, technical review, and alignment with the National Department of Health. This collaborative approach is intended to ensure that the new package is strong, practical, and aligned with national health objectives.
The CMS stated, "In support of the initial costing of the proposed PHC package, the CMS previously requested and received beneficiary membership and claims data from medical schemes. Since then, significant progress has been made in refining the proposed PHC package, aligning the PHC service packages, and undertaking further affordability analyses." This statement from the CMS emphasizes the iterative process involved in developing such a significant reform. The regulator is now requesting updated data from the country’s medical aids to support these ongoing efforts, indicating the continuous need for current and accurate information.
The CMS emphasized the need for current information, stating, "Updated membership and claims data are therefore required to ensure that the costing reflects current use patterns, healthcare expenditure and the refined PHC package." This data request aims to ensure the financial modeling accurately reflects contemporary healthcare utilization and costs associated with the refined PHC package, which is key for its successful implementation. Medical schemes have been given a deadline of the end of October 2026 for the submission of this key data. This extended deadline provides schemes with ample time to compile and submit the full information required by the regulator.
Industry Concerns and Next Steps
The Council for Medical Schemes (CMS) aims to transform Prescribed Minimum Benefits (PMBs) into a new Primary Healthcare (PHC) package. The CMS announced in August that it would launch a new review process to cost this full overhaul, signaling the formal commencement of this critical phase. The updated package now requires revised costing, which necessitates current medical scheme utilisation and expenditure data to ensure accuracy and relevance. The CMS stated, "In support of the initial costing of the proposed PHC package, the CMS previously requested and received beneficiary membership and claims data from medical schemes. Since then, significant progress has been made in refining the proposed PHC package, aligning the PHC service packages, and undertaking further affordability analyses." This reiterates the extensive work already undertaken and the detailed steps involved in preparing for the transformation. Medical aids will have to submit data covering the period from January 1, 2023, to December 31, 2025. This three-year data window is intended to provide a full and recent overview of healthcare trends and costs.
"Updated membership and claims data are therefore required to ensure that the costing reflects current use patterns, healthcare expenditure and the refined PHC package," the CMS added, showing the importance of this data for the financial viability and equitable distribution of the new benefits. The CMS indicated that ten new "PMB Definition Guidelines" will be drafted and communicated to stakeholders. These guidelines are expected to provide clarity and structure to the new PHC package, detailing the scope and nature of the services included. Both the Board of Healthcare Funders (BHF) and the Health Funders Association (HFA) have noted the potential for these changes to increase coverage costs, raising concerns about the affordability and accessibility of medical aid for members. The HFA in 2024 specifically flagged a lack of clarity regarding whether the PHC will function as a standalone set of benefits or be integrated with, or layered on top of, the existing PMB structure. This fundamental question about the architectural design of the new benefits package remains a key point of discussion and concern within the industry. The outcome of this review and the subsequent implementation of the PHC package will significantly reshape the landscape of private healthcare in South Africa.
