R1,600 per member pain for medical aids in South Africa is changing
The Council for Medical Schemes (CMS) has begun its critical review of Prescribed Minimum Benefits (PMBs) for medical aids in South Africa, aiming to transform them into a new Primary Healthcare (PHC) package.
The council announced the shift at the end of August, following years of delays to the review.
South Africa’s PMBs are a package of services that medical aids are legally mandated to cover, including things like chronic illnesses.
Overall, PMBs cover 271 acute and severe medical conditions, accounting for a massive chunk of a medical aid’s monthly costs.
To simply cover these PMBs, medical aid members have to carry a basic minimum cost, estimated at around R1,000, but the cost to schemes can run as high as R1,600 per member.
This is a burdensome fee, making entry points to any medical aid coverage in South Africa unaffordable for most.
Legally, PMB regulations require a review at least every two years; however, South Africa hasn’t changed its core PMB regulations since 2003.
As a result, the PMB burden on medical aids has simply increased over the years, now accounting for about 60% of the billions of rands spent on annual healthcare benefits.
As a remedy to the situation, the CMS has spent years trying to transform the PMB system into a new package based on primary healthcare services (PHC).
In August, following years of delays for various reasons, the CMS announced that it would be launching a new review process to cost the whole thing.
The CMS said that the proposed PHC package has undergone refinement through stakeholder consultation, technical review and alignment with the National Department of Health.
However, the updated package now requires revised costing using current medical scheme utilisation and expenditure data.
To this end, the CMS is now requesting this data from the country’s medical aids.
“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,” it said.
“Since then, significant progress has been made in refining the proposed PHC package, aligning the PHC service packages, and undertaking further affordability analyses.”
Updated membership and claims data are therefore required to ensure that the costing reflects current use patterns, healthcare expenditure and the refined PHC package, it said.
Medical aids will have to submit the related data for the period 1 January 2023 to 31 December 2025, which has to be done by the end of October 2026.
Costing the new system
While the move to review PMBs is critically necessary after more than 20 years without change, concerns have been raised about the reforms’ impact and implementation.
Specifically, the Board of Healthcare Funders (BHF) and the Health Funders Association (HFA) have noted the potential of increasing coverage costs as the packages are changed.
If PHC requirements are implemented alongside PMB requirements—even as the latter is reformed to align with the former—this poses the risk that medical schemes will have to expand basic coverage.
This, in turn, could add an even larger pricing burden, even if only over a shorter time.
The HFA in 2024 flagged a lack of clarity over whether the PHC will act as a standalone set of benefits or be integrated with—or layered on top of—the existing PMB structure.
The group previously noted that even a slight increase in PMB costs may negatively impact medical scheme membership.
Managing Director of the Board of Healthcare Funders (BHF), Katlego Mothudi, also flagged the issue in July 2026, noting that the more that needs to be included as a minimum, crowds out everything else.
While the new packages are being ironed out, the CMS said that ten new “PMB Definition Guidelines” will be drafted and communicated.
This will be to ensure that patients are not subjected to outdated care standards while these broader changes are being finalised.
According to the CMS, these guidelines will update standard treatment protocols and essential medicines lists to reflect modern medical advancements.
However, the costing process is still to be determined.
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