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CMScript 11 of 2021: COVID-19 & vaccines

All medical schemes are required by law to pay for the diagnosis, treatment, care and vaccination costs for COVID-19 as a PMB irrespective of the plan type or option. Details about what constitutes PMB level of care for COVID-19 can be obtained from the PMB definition guideline.

The Minister of Health approved a submission from the Council for Medical Schemes (CMS) for the inclusion of COVID-19 as a Prescribed Minimum Benefit (PMB) condition. As such, on 7 May 2020, the Minister of Health in terms of section 67 of the Medical Schemes Act, 1998 (Act No. 131 of 1998), published an amendment to the Medical Schemes Act Regulations in Notice 515 in Government Gazette 43295.

The amendment required the inclusion of COVID-19 as a PMB condition in the Diagnosis and Treatment Pair (DTP) of the “Respiratory System”. The treatment component for COVID-19 includes screening, clinically appropriate diagnostic tests, medication, medical management including hospitalisation and treatment of complications, and rehabilitation. On 24 December 2020, the Minister of Health approved the inclusion of COVID-19 vaccine under the treatment component for COVID-19.

In cases where the member’s day to day benefits are depleted, schemes must continue funding for the diagnosis, treatment, and care of COVID-19 according to PMB Regulations. Where the member’s option provides for the Medical Savings Account (MSA), PMBs are not supposed to be paid from the MSA as this contravenes the PMB Regulations. Schemes must pay for the cost of involuntary use of a non-DSP where the Designated Service Provider (DSP) was not available.

PMB funding also includes out-of-hospital costs relating to the diagnosis, treatment, and care of the disease. Point (2) of the Explanatory notes and definitions to Annexure A of the PMB Regulations explains that PMBs are not restricted to the setting in which the relevant care should be provided, and should not be construed as preventing the delivery of any prescribed minimum benefit on an outpatient basis or in a setting other than a hospital, where this is clinically most appropriate.

Download the CMScript here

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For all the latest updates regarding the coronavirus pandemic in South Africa, please visit the SA Coronavirus Website.

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