Endometriosis is recognised as a Prescribed Minimum Benefit (PMB) condition in South Africa, but that does not mean that every consultation, scan, medicine or operation is automatically paid in full simply because you have an endometriosis diagnosis.
Understanding the difference between having a PMB diagnosis and qualifying for a particular PMB level of care can help prevent unexpected medical bills.
The Council for Medical Schemes (CMS) specifically recognises endometriosis as a PMB condition. Certain endometriosis ICD-10 codes, including N80.0, N80.1 and N80.2, fall under Diagnosis and Treatment Pair (DTP) 434M.
So, if you have been diagnosed with endometriosis and are worried about paying for treatment privately, the first question should not simply be “Does my medical aid cover endometriosis?”
The better question is:
“Does my specific diagnosis and proposed treatment qualify for PMB funding, and what requirements does my medical scheme have for authorisation?”
What are Prescribed Minimum Benefits?
Prescribed Minimum Benefits are legally defined minimum healthcare benefits that registered South African medical schemes must provide for qualifying conditions.
The CMS explains that PMBs include:
- Emergency medical conditions
- A defined group of Diagnosis and Treatment Pairs
- Chronic conditions included in the Chronic Disease List
PMB care is intended to cover the diagnosis, treatment and care associated with qualifying conditions.
Importantly, PMBs are not simply a list of diseases that medical aids must pay for regardless of circumstances.
A DTP connects a specific diagnosis with the appropriate treatment and care. The treatment must therefore fall within the applicable PMB definition and protocols.
Is endometriosis actually a PMB?
Yes.
This is an important point for South African patients.
The Council for Medical Schemes’ endometriosis guidance states that endometriosis is recognised as a PMB condition.
The relevant ICD-10 codes include:
| ICD-10 code | Description |
|---|---|
| N80.0 | Endometriosis of uterus |
| N80.1 | Endometriosis of ovary |
| N80.2 | Endometriosis of fallopian tube |
These codes are included under DTP 434M, which relates to non-inflammatory disorders and benign neoplasms involving the ovary, fallopian tubes and uterus.
However, the presence of an ICD-10 code by itself does not automatically guarantee PMB payment for every service.
The CMS specifically cautions that ICD-10 codes are used to help identify possible PMB conditions, but the condition must meet the requirements of the applicable PMB definition.
What does PMB cover for endometriosis?
The CMS states that the PMB level of care for endometriosis includes medical and surgical management. Its published endometriosis guidance identifies treatment options within DTP 434M, including medical management and surgical procedures.
That does not mean that every treatment a doctor might theoretically offer is automatically covered.
The proposed treatment needs to correspond with the applicable PMB requirements and treatment protocols.
Think of it this way:
Diagnosis → PMB criteria → appropriate treatment → authorisation/registration → funding according to scheme rules
rather than:
Diagnosis → everything related to endometriosis is automatically free.
Does Discovery Health cover endometriosis?
Discovery Health is required to provide PMB benefits in accordance with the Medical Schemes Act, as are other registered medical schemes.
Discovery explains that PMB access is subject to certain requirements, including that:
- The condition qualifies as a PMB.
- The treatment corresponds with the defined PMB benefits.
- Members use designated service providers (DSPs) where applicable.
- The necessary registration or authorisation processes are followed.
Discovery also states that its plans provide benefits beyond the statutory PMB minimums, but the exact additional benefits depend on the member’s plan.
Therefore, a patient should not assume that her Discovery plan will fund an endometriosis procedure in exactly the same way as another patient’s plan.
What about Bonitas, Momentum and other medical aids?
The PMB requirement applies to registered medical schemes in South Africa, rather than only Discovery.
This means the underlying PMB entitlement for a qualifying condition is not something that a medical scheme can simply remove because a patient is on a particular option.
However, the practical administration can differ between schemes.
Your medical aid may have:
- Different designated service providers
- Different authorisation processes
- Different network arrangements
- Different claims procedures
- Different rules around medicines
- Different benefits above the PMB minimum
- Different processes for registering the condition
The CMS recommends that members understand their scheme rules and determine which providers are designated for PMB treatment.
Does PMB mean you will pay nothing?
Not necessarily.
This is probably the biggest misconception about PMBs.
If you voluntarily use a provider outside your scheme’s designated provider network, a co-payment or shortfall can potentially arise.
The CMS explains that medical schemes may use Designated Service Providers (DSPs) for PMB care. If a member voluntarily chooses a non-DSP, the scheme may pay according to the applicable rules and the member may have to pay the difference.
PMB vs ordinary medical-aid funding
| Situation | What it may mean |
|---|---|
| Qualifying PMB condition | PMB funding may apply |
| Treatment falls within PMB level of care | May be funded as PMB |
| Treatment outside PMB definition | May be paid from ordinary plan benefits, if available |
| Voluntary use of non-DSP | Potential co-payment/shortfall |
| Emergency requiring immediate treatment | Special PMB rules may apply |
| Treatment requiring authorisation | Authorisation should be obtained according to scheme requirements |
| Treatment not meeting PMB criteria | PMB funding may not apply |
Can medical aid make you pay from your Medical Savings Account?
PMB treatment is fundamentally different from ordinary day-to-day healthcare benefits.
The CMS states that medical schemes cannot use a member’s Medical Savings Account (MSA) to pay for PMB costs. PMB funding is intended to come from the scheme’s risk benefits when the relevant requirements are met.
This distinction is important when looking at your medical-aid statement.
If you are told that an account relating to a confirmed PMB condition is being deducted from your savings, ask the scheme to explain why the service was not processed as a PMB claim.
There may be a legitimate reason, for example, the service may not meet the PMB definition, but it is worth clarifying rather than assuming the deduction is correct.
Will medical aid pay for an endometriosis laparoscopy?
This is where patients need to be particularly careful.
A laparoscopy may be medically appropriate for someone with suspected or confirmed endometriosis, but the fact that laparoscopy can be used to investigate or treat endometriosis does not mean every laparoscopy automatically qualifies for PMB funding.
The CMS explains that PMB treatment must correspond with the relevant Diagnosis and Treatment Pair and applicable protocols.
Before booking surgery, ask your gynaecologist’s rooms and medical scheme:
- What is the diagnosis being submitted?
- Which ICD-10 code is being used?
- Does the diagnosis qualify under DTP 434M?
- Is the proposed procedure being requested as PMB?
- Has pre-authorisation been obtained?
- Which hospital is a DSP?
- Is the surgeon part of the relevant network?
- Is the anaesthetist included in the authorisation?
- Are there any expected non-PMB charges?
What documents may be needed?
Medical schemes commonly require documentation to establish the diagnosis and determine whether the proposed care qualifies.
Discovery, for example, states that members should submit medical test results confirming the diagnosis and that the doctor must provide the necessary documentation for PMB registration. Discovery
Your doctor may therefore need to provide information such as:
☐ Confirmed diagnosis
☐ ICD-10 code
☐ Symptoms and clinical findings
☐ Imaging reports
☐ Relevant laboratory/pathology results
☐ Previous treatment history
☐ Reason for proposed treatment
☐ Surgical motivation, where applicable
☐ Procedure codes
☐ Hospital details
☐ Relevant PMB application/authorisation documentation
The exact requirements depend on the medical scheme and the treatment being requested.
A patient’s PMB checklist
Before undergoing treatment for endometriosis, consider asking these questions:
Diagnosis
☐ Has my endometriosis diagnosis been formally documented?
☐ What ICD-10 code has been submitted?
☐ Does my diagnosis meet the applicable PMB criteria?
Treatment
☐ Is my proposed treatment considered PMB-level care?
☐ Is the procedure medically necessary under the applicable treatment protocol?
☐ Is the treatment being submitted as PMB or from my normal plan benefits?
Medical aid
☐ Does my medical aid require pre-authorisation?
☐ Have I registered the condition if required?
☐ Is the hospital a DSP?
☐ Is my gynaecologist part of the relevant network?
☐ Is the anaesthetist included?
☐ Are pathology and radiology costs included?
Costs
☐ Are there any expected co-payments?
☐ Are there any provider shortfalls?
☐ Could any part of the procedure be paid from my normal benefits rather than PMB?
☐ Can I receive written confirmation of the funding decision?
What if your medical aid says “endometriosis isn’t covered”?
Don’t immediately assume that this means endometriosis is not a PMB.
The situation may be more complicated.
Ask the medical scheme to clarify:
“Are you saying my diagnosis does not qualify as a PMB, or that the specific treatment requested does not qualify for PMB funding?”
Those are two very different questions.
Because endometriosis is recognised within the PMB framework, a refusal or limitation should be understood in terms of the specific diagnosis, treatment, protocol, provider and scheme rules, rather than simply the word “endometriosis.”
If you disagree with a medical scheme’s decision, ask for the decision and reason in writing and follow the scheme’s internal complaints and appeal process. The Council for Medical Schemes also provides assistance to members who have disputes concerning medical-scheme benefits.
Normal medical-aid cover vs PMB cover
| PMB funding | Ordinary plan benefits |
|---|---|
| Required by law for qualifying PMB conditions | Determined by your chosen plan |
| Applies regardless of plan option when requirements are met | Varies significantly between plans |
| Based on defined PMB diagnoses and treatment | Broader range of healthcare depending on plan |
| May be subject to PMB protocols | Subject to plan-specific limits and rules |
| DSP arrangements may apply | Network/preferred-provider rules may apply |
| PMB costs should not simply be deducted from MSA when they qualify | Day-to-day expenses may be paid from MSA where applicable |
What about a waiting period?
Medical-scheme waiting periods and PMB rules can be complicated, particularly for new members or people who previously had cover.
The CMS states that PMBs have specific statutory protections, while waiting-period rules can apply in certain circumstances when joining a medical scheme.
Therefore, if you are joining a new medical scheme after receiving an endometriosis diagnosis, do not assume that PMB automatically means immediate access to every form of treatment without any waiting-period considerations.
Ask the scheme for a written explanation of your specific circumstances.
The most important thing to remember
Endometriosis is recognised as a Prescribed Minimum Benefit condition in South Africa.
But PMB does not mean that every expense associated with endometriosis is automatically paid in full.
The actual funding depends on whether your diagnosis meets the relevant PMB definition, whether the proposed treatment falls within the applicable PMB level of care, whether authorisation/registration is required, and whether you follow the medical scheme’s DSP and other applicable rules.
If you’re considering an endometriosis investigation or operation, find out about PMB authorisation before the procedure rather than after you receive the bill.
A few minutes spent confirming your benefits can potentially prevent a very unpleasant financial surprise.
Frequently Asked Questions
Is endometriosis a PMB in South Africa?
Yes. The Council for Medical Schemes recognises endometriosis as a PMB condition, with specified ICD-10 codes included under DTP 434M.
Does Discovery Health cover endometriosis?
Qualifying PMB endometriosis care must be handled according to PMB requirements. Discovery also provides additional benefits beyond the statutory minimum depending on the plan.
Does PMB mean my endometriosis surgery is free?
Not automatically. The diagnosis, treatment, PMB criteria, authorisation and provider arrangements all matter.
Can I choose any private gynaecologist?
Not necessarily for full PMB funding. Medical schemes can require the use of designated service providers, and voluntarily using a non-DSP may result in a shortfall.
Can endometriosis treatment come from my Medical Savings Account?
Qualifying PMB costs should not be funded from the member’s Medical Savings Account.
What should I do before endometriosis surgery?
Ask your doctor and medical scheme to confirm the diagnosis code, PMB status, treatment authorisation, hospital/DSP status and whether any additional costs may be payable by you.
Medical disclaimer
This article is intended for general educational purposes and does not replace individual medical, financial or medical-scheme advice. PMB legislation, scheme rules, benefit structures and authorisation requirements may change. Patients should confirm their specific benefits and funding arrangements directly with their medical scheme and treating healthcare provider. Final publication should be reviewed and approved by an appropriately qualified South African OBGYN and the practice’s compliance team.