Updated: Mar 19
WHAT IS COVERED UNDER PMB (Prescribed Minimum Benefits) LEVEL OF CARE
Diagnosis and management of uncomplicated COVID-19 infection is not included in the PMBs
COVID-19 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 COVID-19 infection – Pneumonia – is a prescribed minimum benefit (PMB) condition under the Diagnosis and treatment pairs (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 & care costs for this condition in full, irrespective of plan type or option. Medical schemes are not allowed to fund PMB conditions from a members medical savings account as this is not in line with the PMB regulations.
In case of uncomplicated COVID-19 infection where there are no PMB-eligible conditions, the scheme may fund all health care costs as per scheme rules.
WHAT ARE PRESCRIBED MINIMUM BENEFITS
Prescribed minimum benefits (PMB’s) are defined by law. They are the minimum level of diagnosis, treatment, and care that your medical scheme must cover – and it must pay for your PMB condition’s from its risk pool and in full. There are medical interventions available over and above those prescribed for PMB conditions but your scheme may choose not to pay for them. A designated service provider (DSP) is a healthcare provider (e.g. Doctor, pharmacist, hospital) that is your medical scheme’s first choice, when you need treatment or care for a PMB condition.
You can use a non-DSP voluntarily or involuntarily, but be aware that when you choose to use a non-DSP, you may have to pay a portion of the bill as a co-payment. PMBs include 270 serious health conditions, any emergency condition and 25 chronic diseases.
How will different Medical Schemes Fund the Coronavirus :
DISCOVERY HEALTH MEDICAL SCHEME
The WORLD HEALTH ORGANISAZTION GLOBAL OUTBREAK BENEFIT is available to all members of Discovery Health Medical Scheme (DHMS) during a declared outbreak period. Once your diagnosis is confirmed, you are covered for out-of-hospital costs for the related treatment from the scheme and not from your day-to-day benefits. Cover includes a defined basket that comprises the diagnostic test, a consultation and defined supportive treatment and medicine. Your chosen plan network rules, where applicable, will also apply to healthcare services paid from WHO GLOBAL OUTBREAK BENEFIT. In hospital treatment related to COVID-19 for approved admissions is covered from the hospital benefit based on your chosen health plan.
Should a member be positively be diagnosed with COVID-19, they will be fully covered for diagnostic testing, consultations and treatment regardless of their scheme option. Bestmed also cover hospitalisation at 100% scheme rates if members are tested positive for COVID-19. Pre-authorisation is required for hospitalisation.
Members on network options need to use their de3signated service providers to be covered.
Coronavirus is covered, Momentum medical scheme will cover the cost of the diagnosis and treatment for confirmed COVID-19 cases. They will cover private hospitalisation when a member with a confirmed diagnosis is symptomatic and requires hospitalisation in terms of the WHO and National Institute of Communicable Diseases (NICD) protocols for COVID-19.
You will be covered if your doctor has performed the test for you. Payment will be from the risk benefit and not from available benefits.
According to Bonitas the government route must first be utilised, because not all service providers in the private sector has been given the power to administer the tests.
This can change at any stage, consult your medical scheme before going for any tests.
Also use the government hotline (0800 029 999) if you suspect that you have the virus.
If the diagnosis is negative, the related tests will be covered from you scheme benefits. Any consultations with medical practitioners will be covered from the normal scheme benefits available on your option. There is no need to be tested more than once, but if you do this, will also be covered in line with available option benefits.
In the case of a positive diagnosis, you, your representative or your healthcare provider, must notify the scheme of the diagnosis as soon as possible. Your healthcare provider will prescribe the necessary care, depending on the severity of your symptoms. The scheme will cover out-of-hospital and/or in-hospital treatment as PMB from risk in line with formularies and other standard managed care protocols.
Testing, diagnosis and consultation will be paid from the members available benefits, savings etc. State pathology services can be used for testes. Coronavirus testing will be funded from private pathology benefit, if members plan type has the benefit. Usually costs R2600 but LANCET has discounted rates on the testing. Coronavirus will only be funded from risk once it has been established it is a PMB.
Profmed will cover all costs related to confirmed cases of COVID-19 irrespective of which option you are. You may need to pay upfront for out-of-hospital tests or consultations and if your tests are positive, they will retrospectively refund your expenses. It is your responsibility to inform the scheme if you have contracted COVID-19 so they can help take care of you and pay any claims.
Claims paid from the day-to-day benefit (If plan type has the benefit) unless advised that it is a PMB.
Once confirmed as PMB, scheme will pay from risk.
Can I get tested at any time for COVID-19 virus?
There are clear testing guidelines from the World Health Organizationand the National Institute for Communicable Diseases and need for testing will be determined by your healthcare professional if you have:
Acute respiratory illness with sudden onset of at least one of the following: cough, sore throat, shortness of breath or fever (>38 C) (measured) or history of fever (subjective) irrespective of admission status and in the 14 days prior to onset of symptoms – met at least one of the following epidemiological criteria:
- Were in close contact with a confirmed or probable case of SARS-COV-2 infection;
Had a history of travel to areas with presumed ongoing community transmission of SARS-COV-2 i.e., Mainland China, South Korea, Singapore, Japan, Iran, Hong Kong, Italy, Vietnam and Taiwan
Worked in/or attended a health care facility where patients with SARS-COV-2 infections were being treated
Admitted with severe pneumonia of unknown cause.
How do I get tested for COVID-19?
Covid-19 is diagnosed by using a polymerase chain reaction (PCR) molecular testing on a sample from the nose, throat or chest.
If you present with symptoms and meet the criteria for testing, do the following:
Contact your doctor who will assess your risk and guide the testing process
Stay at home and avoid contact with others – follow preventative practises to prevent the possible transmission and follow your doctor’s advice about treating your symptoms while waiting for the test results.
What should I do if my local medical Lab cannot test for COVID-19?
State laboratories are the referral point and therefor the starting point. There are other laboratories that also collect epidemiological information on all test subjects to share with the NICD:
Where can I go for treatment?
The following medical facilities have been earmarked for treatment:
Polokwane hospital , Limpopo
Rob Ferreira Hospital, Nelspruit, Mpumalanga
Steve Biko, Thembisa, Gauteng
Grey's Hospital, Kwazulu-Natal
Klerksdorp Hospital , Northern Cape
Kimberley Hospital, Northern Cape
Pelonomi Hospital, Free State
Livingstone Hospital, Western Cape
NICD – 0800 029 999 / 082 883 9920
Most medical schemes will pay for the diagnosis test, consultation and treatment, once it has been confirmed that you have COVID-19, from the risk benefit. Please consult with your medical scheme what benefits you are entitled to; this has only been a short summary of benefits from the different medical schemes.
Please remember that once your condition has been confirmed as a PMB, medical schemes by law must pay for the diagnosis, treatment & care costs for this condition. Remember to use networks and designated service providers if your plan type requires this.
Please contact the medical aid office if anything is unclear or if further assistance will be required.