{"id":875315,"date":"2026-09-14T14:27:59","date_gmt":"2026-09-14T12:27:59","guid":{"rendered":"https:\/\/businesstech.co.za\/news\/?p=875315"},"modified":"2026-09-14T14:28:02","modified_gmt":"2026-09-14T12:28:02","slug":"r1600-per-member-pain-for-medical-aids-in-south-africa-is-changing","status":"publish","type":"post","link":"https:\/\/businesstech.co.za\/news\/lifestyle\/875315\/r1600-per-member-pain-for-medical-aids-in-south-africa-is-changing\/","title":{"rendered":"R1,600 per member pain for medical aids in South Africa is changing"},"content":{"rendered":"\n

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.<\/p>\n\n\n\n

The council announced the shift at the end of August, following years of delays to the review.<\/p>\n\n\n\n

South Africa’s PMBs are a package of services that medical aids are legally mandated to cover, including things like chronic illnesses. <\/p>\n\n\n\n

Overall, PMBs cover 271 acute and severe medical conditions, accounting for a massive chunk of a medical aid’s monthly costs.<\/p>\n\n\n\n

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<\/strong><\/a> per member.<\/p>\n\n\n\n

This is a burdensome fee, making entry points to any medical aid coverage in South Africa unaffordable for most.<\/p>\n\n\n\n

Legally, PMB regulations require a review at least every two years; however, South Africa hasn’t changed its core PMB regulations since 2003.<\/p>\n\n\n\n

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.<\/p>\n\n\n\n

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).<\/p>\n\n\n\n

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.<\/p>\n\n\n\n

The CMS said that the proposed PHC package has undergone refinement through stakeholder consultation, technical review and alignment with the National Department of Health. <\/p>\n\n\n\n

However, the updated package now requires revised costing using current medical scheme utilisation and expenditure data.<\/p>\n\n\n\n

To this end, the CMS is now requesting this data from the country’s medical aids.<\/p>\n\n\n\n

“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.<\/p>\n\n\n\n

“Since then, significant progress has been made in refining the proposed PHC package, aligning the PHC service packages, and undertaking further affordability analyses.”<\/p>\n\n\n\n

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.<\/p>\n\n\n\n

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.<\/p>\n\n\n\n

Costing the new system<\/h2>\n\n\n\n
\"\"<\/a>
Board of Healthcare Funders Managing Director, Dr Katlego Mothudi<\/figcaption><\/figure>\n\n\n\n

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.<\/p>\n\n\n\n

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.<\/p>\n\n\n\n

If PHC requirements are implemented alongside PMB requirements\u2014even as the latter is reformed to align with the former\u2014this poses the risk that medical schemes will have to expand basic coverage.<\/p>\n\n\n\n

This, in turn, could add an even larger pricing burden, even if only over a shorter time.<\/p>\n\n\n\n

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\u2014or layered on top of\u2014the existing PMB structure.<\/p>\n\n\n\n

The group previously noted that even a slight increase in PMB costs may negatively impact medical scheme membership.<\/p>\n\n\n\n

Managing Director of the Board of Healthcare Funders (BHF), Katlego Mothudi, also flagged the issue in July 2026<\/strong><\/a>, noting that the more that needs to be included as a minimum, crowds out everything else.<\/p>\n\n\n\n

While the new packages are being ironed out, the CMS said that ten new “PMB Definition Guidelines” will be drafted and communicated.<\/p>\n\n\n\n

This will be to ensure that patients are not subjected to outdated care standards while these broader changes are being finalised.<\/p>\n\n\n\n

According to the CMS, these guidelines will update standard treatment protocols and essential medicines lists to reflect modern medical advancements.<\/p>\n\n\n\n

However, the costing process is still to be determined.<\/p>\n","protected":false},"excerpt":{"rendered":"

Prescribed Minimum Benefits in South Africa are under review, with the CMS setting a deadline for medical aids to submit their data.<\/p>\n","protected":false},"author":10,"featured_media":836601,"comment_status":"open","ping_status":"closed","sticky":true,"template":"","format":"standard","meta":{"_sma_x_autopost_status":"posted","_sma_x_autopost_error":"","_sma_x_post_id":"2099475516017324377","_sma_facebook_post_id":"191437357620492_2205257040294695","_sma_instagram_post_id":"17903005146588622","_sma_x_attempts":1,"footnotes":""},"categories":[9876],"tags":[10405,10068],"class_list":["post-875315","post","type-post","status-publish","format-standard","has-post-thumbnail","hentry","category-lifestyle","tag-cms","tag-medical-aid"],"_links":{"self":[{"href":"https:\/\/businesstech.co.za\/news\/wp-json\/wp\/v2\/posts\/875315","targetHints":{"allow":["GET"]}}],"collection":[{"href":"https:\/\/businesstech.co.za\/news\/wp-json\/wp\/v2\/posts"}],"about":[{"href":"https:\/\/businesstech.co.za\/news\/wp-json\/wp\/v2\/types\/post"}],"author":[{"embeddable":true,"href":"https:\/\/businesstech.co.za\/news\/wp-json\/wp\/v2\/users\/10"}],"replies":[{"embeddable":true,"href":"https:\/\/businesstech.co.za\/news\/wp-json\/wp\/v2\/comments?post=875315"}],"version-history":[{"count":1,"href":"https:\/\/businesstech.co.za\/news\/wp-json\/wp\/v2\/posts\/875315\/revisions"}],"predecessor-version":[{"id":875331,"href":"https:\/\/businesstech.co.za\/news\/wp-json\/wp\/v2\/posts\/875315\/revisions\/875331"}],"wp:featuredmedia":[{"embeddable":true,"href":"https:\/\/businesstech.co.za\/news\/wp-json\/wp\/v2\/media\/836601"}],"wp:attachment":[{"href":"https:\/\/businesstech.co.za\/news\/wp-json\/wp\/v2\/media?parent=875315"}],"wp:term":[{"taxonomy":"category","embeddable":true,"href":"https:\/\/businesstech.co.za\/news\/wp-json\/wp\/v2\/categories?post=875315"},{"taxonomy":"post_tag","embeddable":true,"href":"https:\/\/businesstech.co.za\/news\/wp-json\/wp\/v2\/tags?post=875315"}],"curies":[{"name":"wp","href":"https:\/\/api.w.org\/{rel}","templated":true}]}}