Join the Medical Aid for South Africa for All Life Stages.

These are healthcare professionals or providers that Bonitas Medical Fund has selected as the first choice for the diagnosis and treatment of members’ healthcare needs. Designated Service Providers must be used for both Prescribed Minimum Benefit (PMB) and non-PMB situations.

The Prescribed Minimum Benefit (PMB) list of conditions lists all of the conditions which all medical schemes need to cover on all the health plans they offer to their members. This cover includes funding for the diagnosis, treatment and ongoing care for the listed conditions.

According to the Medical Schemes Act 131 of 1998 and its Regulations, all medical schemes have to cover the costs related to the diagnosis, treatment and care of:

1. Any life-threatening emergency medical condition
2. A defined set of 271 diagnoses
3. 27 chronic conditions (Chronic Disease List (CDL) conditions)

The 271 diagnoses and 27 chronic conditions (Chronic Disease List (CDL) conditions) that qualify for Prescribed Minimum Benefit (PMB) cover are diagnosis-specific and include a range of ailments that are divided into 15 broad categories.

This information is directly available from the Council for Medical Schemes (CMS) at www.medicalschemes.co.za. This list may change from time to time, please refer to the CMS website for a full list of the 271 diagnostic treatment pairs.

For certain procedures, or if you or any of your dependants are admitted to hospital, pre-authorisation must be obtained from the Scheme.

You can get pre-authorisation for in-hospital benefits such as hospital admissions, specialised radiology, and doctor’s room procedures in any of the following ways:

• Website
• WhatsApp
• Call
• Email

For hospital admissions, specialised radiology, and doctor’s room procedures, you need the following details:

• Your membership number.
• The name and details of the patient.
• The reason for hospital admission, procedure, or specialised scan.
• The procedure code (CPT), diagnosis code (ICD-10), and tariff code.
• Date of admission.
• The contact details and practice number of the referring GP.
• The contact details and practice number of the specialist.
• The name and practice number of the hospital or day clinic.

In terms of the Medical Schemes Act, medical schemes may apply waiting periods to new members or dependants joining the Scheme. This depends on the beneficiary’s health risk status and their previous medical scheme membership history.

If a 3-month general waiting period is applied, you must wait 3 months from the date that your membership commences before you can claim from your medical scheme benefits.

A 12-month waiting period may also be applied to specific medical conditions. If this waiting period is applied, you must wait 12 months from the date your medical scheme membership starts before you can claim benefits for the condition.