PROTECTING MEDICAL SCHEME MEMBERS THROUGH A PANDEMIC

THE outbreak of the coronavirus set off an unprecedented ripple of serious health, economic, social and political challenges. As a responsive regulator, the Council for Medical Schemes (CMS) put in motion various regulatory interventions to ensure the protection of the interests of members, while maintaining a sustainable industry in a tough climate.

In concurrence with the Department of Health, Covid-19 was gazetted as a Prescribed Minimum Benefit (PMB) condition, making way for all registered schemes to fund the diagnosis, treatment, care, vaccination and rehabilitation of the infection.

What is covered under PMB level of care Covid-19?

Screening, vaccination, diagnostic tests and medical management, including hospitalisation of Covid-19 infections, is a new diagnosis treatment pair included as part of the PMBs diagnoses list. 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 may not fund PMB conditions from a member’s medical savings account, as this would be in violation of the PMB regulations.

In addition, any complications arising from infection with Covid-19 such as pneumonia, respiratory failure, renal failure, complete or partial lung collapse, among others, are already included in the list of existing PMB conditions and should be treated as specified for each condition.

Some complications would also usually qualify as emergency medical conditions and are therefore PMBs.

How are vaccines funded?

Identification and prioritisation of the scheme’s members and beneficiaries to be vaccinated should be aligned with the National Department of Health’s guidelines.

All SAHPRA-approved vaccinations for Covid-19 must be funded for beneficiaries identified and prioritised as guided by the Ministerial Advisory Committee (MAC). There is no co-payment for members at the point of vaccine administration.

All Covid-19 vaccinations administered outside South Africa will be funded at the discretion of the scheme based on the scheme’s rules. Management of all side effects and complications, which may result from administration of the Covid-19 vaccine, must be reimbursed by the medical scheme.

Which Covid-tests are PMB?

RT-PCR and/or antigen testing are PMB level of care for diagnosis of Covid-19. These tests are paid for when a member is screened and referred by a healthcare worker. RT-PCR tests for unscreened, asymptomatic and unreferred members are only considered PMB level of care if the test result is positive. Payment of antigen tests is slightly different, as the accuracy of the results is dependant on the probability of getting an accurate result prior to even testing. Antigen tests are only PMB level of care when there is a high probability of an accurate test.

How often will tests be paid?

The number of RT-PCR and antigen tests per member should not be capped for a member who is screened and referred upon presenting with Covid-19 symptoms.

A repeat PCR test to confirm diagnosis is not PMB level of care. A repeat PCR test to confirm that the member is no longer positive is not covered as PMB level of care.

A PCR test may be required to confirm a negative antigen test when there is a high probability of an accurate test. A PCR test is not required to confirm a positive antigen test when there is already a high probability of an accurate antigen test.

Is oxygen paid for by the scheme?

Oxygen in and out of hospital is PMB level of care, depending on the oxygen saturation results.

Other regulatory interventions

The CMS is tasked to, among others, provide measures for the control and co-ordination of medical schemes, administrators, managed care organisations and brokers, and most importantly, to protect the interests of members of medical schemes.

To protect beneficiaries who were financially affected by the Level 5 lockdown and the limit to commercial activity, the CMS set a dispensation where medical schemes could utilise accumulated medical savings to offset their contributions. This concession included allowing schemes the use of ex-gratia payments to financially assist their

members.

The CMS also extended a hand to SMMEs with less than 200 employees, allowing schemes to make payment arrangements with these businesses in order to protect their employees’ cover.

In order for members of medical schemes to access their medical scheme’s annual general meetings, the CMS issued guidelines to schemes on successfully running AGMs and SGMs virtually.