The Council for Medical Schemes (CMS) has released an updated version (V3) of its PMB definition guideline for COVID-19 which includes an insertion of the Diagnosis and Treatment Pair in the list of PMBs under the heading “Respiratory System”.
The treatment component now includes screening, clinically appropriate diagnostic tests, medication, medical management including hospitalisation and treatment of complications, and Rehabilitation of COVID-19
“This guideline seeks to clarify PMB entitlements of medical scheme beneficiaries within the context of the pandemic, ensuring that there is uniform interpretation amongst all stakeholders,” the CMS explains in its introductory note.
“It sets out recommendations for the screening, diagnosis, treatment and care of individuals with suspected and confirmed COVID-19 as per WHO case definitions.”
Major changes in the new version include:
· Reporting of confirmed cases only, and not both confirmed and suspected cases
· Changes in the case definition to align with NICD guidelines
· Defining close contacts and removal of high-risk persons criteria
· More clarity on funding of RT-PCR testing is provided as a separate section
· Addition of specific criteria for CT scan
· Cough suppressants not 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 complete guideline can be accessed at https://www.medicalschemes.com/files/PMB%20Benefit%20definition%20guidelines/PMB_definition_guideline-COVID-19_v3_11_June_2020.pdf