The Primary Healthcare Benefits Review: What Private Practitioners Need To Watch
A major review of South Africa’s Prescribed Minimum Benefits is entering an important phase. What could a proposed Primary Healthcare package mean for medical schemes, private practitioners and patients?
South Africa’s healthcare system is entering an important phase in the review of Prescribed Minimum Benefits (PMBs), and private practitioners should be paying attention. On 14 September 2026, the Council for Medical Schemes (CMS) issued Circular 26 of 2026, requesting medical schemes and administrators to submit membership and claims data for 1 January 2023 to 31 December 2025. The information must be submitted by 15 October 2026 and will support the costing of a proposed Primary Healthcare (PHC) service benefits package, as well as affordability analysis and implementation planning.
For practitioners, this is more than an administrative exercise. PMBs influence the benefits medical scheme members are entitled to, how those benefits are financed and, ultimately, how healthcare is accessed and delivered.
Why does the PMB review matter?
PMBs are defined benefits that medical schemes are required by law to cover, subject to applicable legislation and regulations. They are intended to provide members with access to a minimum level of healthcare. The current review recognises that the existing PMB framework needs to respond to changing healthcare needs, developments in clinical practice and technology, South Africa’s burden of disease, health policy priorities and affordability.
A key focus is primary healthcare, including prevention, screening, early diagnosis, treatment and ongoing management of conditions. A stronger PHC focus could have implications for:
- prevention and early intervention
- chronic disease management
- screening and early diagnosis
- mental healthcare
- continuity of care
- referrals
- access to GPs and other primary healthcare providers.
However, it is important to distinguish between a proposed package being reviewed and costed and a final benefit becoming an approved entitlement. The current process does not determine the final scope, cost or implementation model.
Why is the CMS requesting data?
The CMS data request will provide evidence about healthcare utilisation and costs and help answer three key questions:
- What will the proposed package cost?
- Will it be affordable for medical schemes and their members?
- What would implementation require?
The 15 October 2026 deadline is therefore an important milestone in the broader review.
What could this mean for private practitioners?
It is too early to determine the final impact, but practitioners should watch three areas closely.
1. The scope of primary healthcare
Which services will be included? How will prevention, screening, diagnosis and chronic disease management be addressed? Where will the boundaries between primary, secondary and tertiary care sit? The answers will influence what patients can access and what providers may be expected to deliver.
2. The role of doctors and dentists
A stronger PHC orientation could increase the importance of GPs and other primary-care providers in prevention, early diagnosis, chronic disease management, referrals and continuity of care. For dental practitioners, the review is also relevant to the broader discussion around essential healthcare benefits, affordability and access. Practitioners should understand how any revised framework could interact with existing dental benefits and funding arrangements.
The key question is not simply whether primary healthcare receives greater recognition, but whether the financing model supports sustainable care.
3. The economics of private practice
A sustainable PHC model requires alignment between:
benefits + utilisation + tariffs + provider costs + medical scheme affordability + patient access.
Expanding benefits without adequately considering the cost of delivering care could place additional pressure on practices. On the other hand, better-supported primary healthcare could create opportunities for earlier intervention, improved chronic disease management and more coordinated care. Practitioners should therefore follow developments around provider tariffs, contracting, networks and reimbursement models alongside the benefit review itself.
What should practitioners be watching?
Practitioners should closely monitor:
- the broader PMB Review and how the existing framework may evolve
- the scope of the proposed Primary Healthcare package
- costing and affordability
- provider tariffs, contracting and sustainability
- the relationship between the PMB review and broader healthcare reform, including Universal Health Coverage.
Practitioners should also engage through their professional bodies where opportunities arise for stakeholder input. Most importantly, distinguish between what has been proposed, what is being costed, what is being consulted on and what has actually been approved.
Why this matters to SAMDP members
For SAMDP members, the PMB review is not simply a regulatory issue. It sits at the intersection of patient access, affordability, provider sustainability and the future of private healthcare in South Africa. A healthcare system cannot be sustainable if patients cannot afford care. But it also cannot be sustainable if healthcare professionals cannot sustainably provide that care. The challenge is finding the right balance between access, affordability, quality and sustainability.
What happens next?
The immediate milestone is 15 October 2026, when medical schemes are required to submit the requested membership and claims data to the CMS. This will contribute to the costing of the proposed PHC service benefits package and subsequent affordability analysis and implementation planning. But 15 October is not the end of the process. It is another step in a much larger review.
For private practitioners, the message is simple:
Watch the process. Understand the implications. Ask the right questions and make sure the voice of the practitioner remains part of the conversation.
SAMDP will continue to monitor developments affecting medical and dental practitioners and the broader private healthcare environment. Practitioners should also consult the CMS and its published circulars and PMB resources for official updates.
Important: This article is intended for general information and does not constitute legal, financial or clinical advice. The proposed Primary Healthcare service benefits package remains subject to the ongoing PMB review, costing, affordability analysis, policy and implementation processes. Practitioners should refer to official CMS communications for definitive information as the process develops.
Sources:
Council for Medical Schemes, Circular 26 of 2026; CMS Prescribed Minimum Benefits Review documentation; CMS Annual Report 2024/25.
Official source of this article: https://www.medicalschemes.co.za/latest-publication/circular-26-of-2026-request-for-membership-and-claims-data-for-the-costing-of-the-proposed-primary-healthcare-service-benefits-package
This broader CMS PMB review document is also useful: https://www.medicalschemes.co.za/download/2094/pmb-review/15498/pmb-review-consultative-doc.pdf
