MHM Magazine

6 | MENTAL HEALTH MATTERS | 2025 | Issue 5 MHM Introduction The Council for Medical Schemes (CMS) is an autonomous statutory body established by the South African Parliament to regulate medical schemes and ensure members receive equitable healthcare benefits. One of the CMS’s key mandates is to define Prescribed Minimum Benefits (PMBs) — the minimum level of healthcare services that medical schemes are required by law to fund in full and without a co- payment. Recently, the CMS introduced detailed PMB Definition Guidelines for Schizophrenia and Bipolar Disorder, two severe mental health conditions that often require complex, multidisciplinary care. These guidelines aim to standardise the quality and continuity of mental healthcare for all medical scheme members, regardless of their chosen benefit option. However, despite the clarity and comprehensiveness of these new PMB definitions, both patients and healthcare providers are facing significant challenges in ensuring medical schemes fully adopt and implement them. Medical schemes often argue that these “guidelines” are merely “guidelines” and that they don’t have to be followed. The CMS has however made it very clear that these guidelines have to be followed and the benefits as specified in the guidelines are PMBs. It’s important that patients and families of patients are made aware of these guidelines. Overview of the PMB Definition Guidelines Schizophrenia According to the medical schemes act, act 131 of 1998 and its regulations, patients with schizophrenia have PMBs under the diagnosis/treatment (DTP) pair section as well as under the so-called chronic disease list (CDL) section. Most medical schemes only apply the benefits as specified in the DTP section and ignore the CDL section. Under the DTP section, patients diagnosed with schizophrenia are entitled to a maximum of 21 days of in-hospital care per year for acute management without any PMBs for outpatient care. The new PMB Definition Guideline for Schizophrenia, clarifies the PMBs for both the DTP and CDL sections. Beyond hospitalization, the guidelines emphasize the importance of ongoing outpatient care and multidisciplinary interventions. Key entitlements include: At least one diagnostic consultation with a psychologist or doctor, leading to referral to a multi-professional team (psychiatrist, GP, psychologist, occupational therapist, social worker). This team must then further investigate and confirm the diagnosis through several assessments, including: • a full psychiatric and medical history including a mental state and physical examination • a psychosocial assessment and a psychological By Dr Eugene Allers Psychiatrist, Gauteng CHALLENGES IN IMPLEMENTING THE COUNCIL FOR MEDICAL SCHEMES PMB DEFINITION GUIDELINES FOR SCHIZOPHRENIA AND BIPOLAR DISORDER IN SOUTH AFRICA MHM | 2025 | Volume 12 | Issue 5 | Challeng s in Implementing the Council for Medical Schemes PMB Definition Guidelines for Schizo- phrenia and Bipolar Disorder in South Africa H