With South Africa reporting its first confirmed case of the COVID-19 coronavirus on Thursday (4 March), the Council for Medical Schemes (CMS) has outlined how the country’s medical schemes must offer cover for the virus.
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.
Prescribed Minimum Benefits or PMBs are a set of defined benefits that ensures all medical scheme members have access to certain minimum health services, regardless of their benefit option.
While this me 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 are no PMB-eligible conditions, the scheme may fund all health care costs as per scheme rules,” it said.
In a notice sent to customers on Thursday (5 March), South Africa’s largest private medical scheme Discovery said that all primary care cover policyholders will have access to full funding for testing and treatment costs, for confirmed COVID-19 cases.
“Primary care members should continue to depend on their existing network of healthcare professionals. This cover is available during the period of the COVID-19 outbreak.”
To maximise benefits and cover available to its gap cover clients, Discovery said it will also waive any waiting periods in place for current Discovery Gap Cover policyholders, and settle all valid claims where COVID-19 is diagnosed.
“Doctors can only treat the symptoms of COVID-19 as they present. No specific therapy has been shown to be effective against the virus itself,” said Dr Ryan Noach, chief executive officer of Discovery Health
“If you feel ill and have any of the symptoms of infection with COVID-19 you must seek medical care early and share your previous travel history with your healthcare provider,” he said.