Coronavirus | How is it funded by medical schemes?

The Council for Medical Schemes (CMS) recently released a CMScript detailing key information about the symptoms, spread, diagnosis and treatment of Coronavirus. The publication confirmed the following regarding medical scheme cover for Coronavirus.

CMS Confirmation of treatment

“Diagnosis and management of uncomplicated Coronavirus infection is not included in the Prescribed Minimum Benefits (PMBs). Coronavirus infection may, however, result in various complications. 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 Coronavirus infection – Pneumonia – is a prescribed minimum benefit (PMB) condition under the Diagnosis and Treatment Pair (DTP) code 903D. This DTP refers to “Bacterial, viral, fungal pneumonia.

The treatment component for this condition is specified as “Medical management, ventilation”. 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 PMB Regulations. In cases of uncomplicated Coronavirus infection where are no PMB-eligible conditions, the scheme may fund all health care costs as per the scheme rules.”

What this means for medical scheme members

If a member has uncomplicated Coronavirus, funding of diagnosis and treatment will be done in the same way as a person diagnosed with a cold. If the member experiences complications that lead to a condition that is a PMB, then diagnosis and treatment of that PMB will be covered from the scheme’s risk benefits.

Some medical schemes have communicated to their members around their cover for Coronavirus. NMG will update you with any additional communication received from schemes as and when they occur.

The information in this communication is for information purposes and is not intended to be detailed advice described in the Financial Advisory and Intermediary Services Act. The fund, administrator and trustees cannot be held liable for damage or loss suffered as a result of any action that you take based on the contents of this communication.