News Release

March 2020

Covid-19 and your medical scheme benefits

What is covered under PMB level of care?

According to the Council for Medical Schemes (CMS), diagnosis and management of uncomplicated COVID-19 infection is not included in the Prescribed Minimum Benefits (PMBs). COVID-19 infection may, however, result in various complications which are. 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. This DTP refers to “Bacterial, viral, fungal pneumonia”. The treatment component for this condition is specified as “Medical management, ventilation”.

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 are no PMB-eligible conditions, the scheme may fund all health care costs as per scheme rules.

PMBs include 270 serious health conditions, any emergency condition, and 25 chronic diseases. These can be found on the CMS website (www.medicalschemes.com)

It is also important to note that most medical schemes have already applied specific protocols that one would need to follow in terms of COVID-19.

(Reference – The Council for Medical Schemes, CMS Script, Issue 1 of 2020)

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