The Council for Medical Schemes has requested that schemes offer leniency to members who miss payments due to the country’s 21-day coronavirus lockdown.
“In the spirit of social solidarity as outlined by the president during his address to the nation on Monday, 23 March 2020, the CMS requests that schemes investigate all disruptions to member contributions,” the group said in a circular sent to schemes on Thursday (26 march),.
The CMS further asked schemes to assess non-payment on a case by case basis and determine the merits thereof, prior to termination. The CMS has already indicated 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 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.