The Council for Medical Schemes (CMS) recently published two documents of note pertaining to the Coronavirus pandemic. These are the CMS Script Issue 1 of 2020 and Circular 25 of 2020.
CMS Script Issue 1 of 2020 on the Coronavirus Disease (COVID-19) provides background information on the coronavirus outbreak, how the virus is spread, the risk factors for acquiring the infection and how to prevent same. The CMS publication also includes information on the symptoms, diagnosis as well as treatment and management of the infection. It was noted in this publication, which was issued during early March 2020, that the diagnosis and management of uncomplicated COVID-19 infection is not included in the Prescribed Minimum Benefits (PMBs). However, this position has since changed as noted in a subsequent publication from the CMS on 26 March 2020.
Circular 25 of 2020: COVID-19 lockdown measures states that all cases of COVID-19 are regarded as a PMB condition and should be funded in full in line with the current National Institute for Communicable Diseases (NICD) guidelines as published, and which is also included as a link in Circular 25 of 2020.
PMBs are defined by law and are the minimum level of diagnosis, treatment, and care that a medical scheme must cover from its risk pool. In line with clinical protocols and benefit guidelines, Circular 25 of 2020 states that this should cover: all consultations, all clinically appropriate diagnostic tests including Viral PCR, all clinically appropriate medication and costs of hospitalisation including all complications and rehabilitation.
Circular 25 of 2020 also discusses the current stance taken relating to membership fees. In cases of non-payment, the CMS requests that medical schemes investigate all disruptions to member contributions on a case by case basis and determine the merits thereof, prior to termination of membership – this is in line with the spirit of social solidarity as outlined by the President during his address to the nation on 23 March 2020. Further, with regard to price and tariff negotiations the circular states that the CMS supports such negotiations between key players aimed at improving access to care, prevention of exploitation of patients and cost reduction in the health sector as reflected in section 4 and 5 of Regulation No. 43114 published by the Ministry of Trade and Industry. Section 4 and 5 of the same regulation provides that at the request of the Department of Health, and subject to the oversight and guidance by the Department of Health, agreements must accordingly be approved and duly authorised by the Minister of Health.