The Council for Medical Schemes (CMS) recently published PMB definition guideline: COVID-19 v3 which is an updated version of the Prescribed Minimum Benefits for COVID-19. This document may change as guidance changes and users should always check for updates on the National Institute for Communicable Diseases (NICD) and the National Department of Health (DOH) websites. The guideline also contains what is not recommended as PMB level of care for COVID-19.
The major changes in this version of the PMB guideline expands on:
- Reporting of confirmed cases only, and not both confirmed and suspected cases.
- Changes in the case definition (e.g. meaning of a “confirmed case” and a “suspected case”) to align with NICD guidelines.
- Defining close contacts as a person having had face-to-face contact or having been in a closed space with a confirmed COVID-19 case for at least 15 minutes. The guideline includes some examples.
- Previously high-risk persons were defined separately to the suspected case definition. However, they have now been included in the new definition with the exception of people who are admitted with pneumonia.
- More clarity on funding of RT-PCR (reverse transcriptase polymerase chain reaction) testing is provided as a separate section. Latest guidance states that diagnosis of the virus is only confirmed by this test. In terms of the updated guideline, the RT-PCR test should be funded from the risk benefit irrespective of the result. Because a single positive test is sufficient proof of COVID-19 infection, and there is no role of repeat confirmatory test, a repeat confirmatory test is not PMB level of care.
- Addition of specific criteria for CT scan, which is recommended in certain instances.
- Cough suppressants (e.g. cough mixtures) are not recommended as PMB level of care for COVID-19.
- More clarity on funding of out of hospital symptomatic medication for COVID-19.
- Funding guidance on people living with HIV, children, newborns, pregnant and breastfeeding women.
- Funding of personal protective equipment (PPE) and asymptomatic people returning to work. The department of labour has issued guidance on workplace preparedness for COVID-19 and employers are obligated to provide workers with appropriate PPE to keep them safe while performing their duties. PPE is currently not recommended as PMB level of care irrespective of the level of costs and cannot be transferred to members or schemes.