The Council for Medical Schemes (CMS) has outlined how the country’s medical schemes must offer cover for the virus. Business Tech reports that in a circular sent out to medical schemes, the CMS said that the diagnosis and management of uncomplicated COVID-19 infection is not included in South Africa’s Prescribed Minimum Benefits.
While this may be a cause of concern for South Africa medical aid members, the CMS noted that the COVID-19 infection may result in various complications and that most of the complications are included in the PMBs and should be treated as specified for the specific condition. “One of the most common complications of COVID-19 infection – pneumonia – is a prescribed minimum benefit (PMB) condition under the Diagnosis and Treatment Pair (DTP) code 903D,” it said.
“All medical schemes are required by law to pay for the diagnosis, treatment and care costs for this condition in full irrespective of plan type or option. Medical schemes are not allowed to fund PMB conditions from a member’s Medical Savings Account, as this is not in line with the PMB Regulations. In cases of uncomplicated Covid-19 infection where there are no PMB-eligible conditions, the scheme may fund all health care costs as per scheme rules,” it said.
Discovery Health Medical Scheme, South Africa’s largest open medical scheme, will fund the costs of tests and treatment for its members who contract the coronavirus. Discovery Health CEO Ryan Noach has announced that the scheme had developed the DHMS WHO Global Outbreak Benefit to pay for the diagnosis and treatment of the coronavirus in full for all its members. Business Day reports that to be eligible for this cover, however, the illness must be confirmed as a case of what is known as COVID-19.
As the flu season starts in mid-March, more people will start showing signs of flu, which are also the first signs of the coronavirus. But, the report says, if members suspect they have the virus and are sent for tests, but test negative, the scheme will only provide its usual benefits, which for Discovery members means any costs incurred for tests will be paid from their medical savings accounts.
Testing for the coronavirus will be done by state laboratories not private labs, however.
With the COVID-19 cases confirmed in the country, the Council for Medical Schemes has announced that that for members of a scheme with an uncomplicated infection, the scheme is only obliged to pay for treatment in line with its benefit rules. Only if the virus progresses and results in complications such as pneumonia and respiratory failure, which are prescribed minimum benefits, will the scheme be obliged to pay for a member’s tests and treatment, Dr Sipho Kabane, the CEO and registrar of the council said.
[link url="https://businesstech.co.za/news/business/379527/this-is-how-south-african-medical-aids-will-cover-the-covid-19-coronavirus/"]Full Business Tech report[/link]
[link url="https://www.medicalschemes.com/files/CMScript/CMScript%201-2020.pdf"]CMS circular[/link]
[link url="https://www.businesslive.co.za/money/2020-03-06-discovery-to-pay-for-all-coronavirus-care-for-members/"]Full Business Day report[/link]