COVID-19 is a Prescribed Minimum Benefit (PMB) condition. This means that the Scheme is obliged to cover the diagnosis, treatment and care costs for the condition. But not all the tests and investigations used to diagnose COVID-19 and treatments for the condition are considered PMB level of care.
The Council for Medical Schemes (CMS) has published a PMB Definition Guideline for COVID-19, which entitles beneficiaries to funding for PCR testing, doctors’ consultations, acute medication, and other specified treatment and interventions. These benefits are all subject to protocols and Scheme rules.
What benefits do I have?
Each beneficiary is entitled to one face-to-face consultation or one tele-medicine consultation per beneficiary per annum. Payment of the consultation is subject to use of a General Practitioner, the Scheme’s Designated Service Provider (DSP). The Scheme covers PCR tests out-of-hospital where appropriate screening has been done and the test recommended by a GP. One test per annum per beneficiary is covered for admission to hospital, irrespective of whether the test is positive or negative.
Claims for PCR tests will only be funded if the test results from the laboratory and proof of consultation with a GP have been validated on the system. All funding is strictly in terms of protocols and Scheme rules.
Benefit options with no day-day benefits
Members on the ProActive, ProActive Savvy, ProActive Plus, ProActive Plus Savvy options do not have access to day-to-day benefits or have limited day-to-day benefits. Therefore, claims submitted to the Scheme will be automatically rejected for benefits not available. In this instance, it is necessary for members to submit either proof of a positive result or proof of consultation with a GP to firstname.lastname@example.org.
Benefit options with available day-day benefits
Claims on the ProSecure, ProSecure Savvy, ProSecure Plus, ProSecure Plus Savvy, ProPinnacle and ProPinnacle Savvy options will first pay from the available day-to-day benefits, once validated. If the day-to-day benefits have been depleted, only PMBs will continue to pay thereafter. In the event claims are rejected due to insufficient benefits, members must submit either proof of a positive result or proof of consultation with a GP to email@example.com.