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COVID-19: Council for Medical Schemes COVID-19 PMB Definition update - version 4
Dear SAMA members
The South African Council for Medical Schemes has published the 4th version of the COVID-19 Prescribed Minimum Benefit (PMB) Guideline for practitioners and medical schemes.
COVID-19 has been a prescribed minimum benefit in terms of the Medical Schemes Act since May 2020 through declaration in the Government Gazette, and publication of a PMB Definition for COVID-19 by the CMS.
Since then there have been three new updates to the PMB Definition.
Major Changes in version 4 of the PMB Definition:
- Inclusion of palliative care Palliative care
is included for confirmed positive cases suffering from severe disease, and recommendations are made for how to claim for multi-disciplinary care to be provided.
- Recommendation on corticosteroid use, remdesivir, chloroquine or hydroxychloroquine prophylaxis, convalescent plasma
Recommendations draw from the recommendations made by the National Essential Medicines List Committee (NEMLC). Only low dose corticosteroid treatment is PMB level of care for severe cases, hospitalised and requiring respiratory support. Other therapies should be funded in line with scheme rules and protocols.
- Funding of PPE for confirmed cases
PPE for health workers who are treating and managing suspected and confirmed COVID-19 patients may claim for the PPE as part of the consumables for the patients and included in the PMB level of care. Claims may be backdated to 7 May 2020, when the PMB regulations for COVID-19 were promulgated.
- Emphasis on blood saturation results not gases for oxygen funding
Funding of oxygen for COVID-19 is recommended based on the oxygen saturation results. Given the pandemic and limited health resources, blood gases are not a pre-requisite for oxygen funding. The only recommended criterion for COVID-19 is for a patient to meet the oxygen saturation required.
- Amendment to radiology codes
Amended and additional X-ray and CT Codes have been included
- Inclusion of non-invasive ventilation
If clinical setting is appropriate and there is provider preference, non- invasive ventilation is recommended as PMB level of care in line with the NICD guidelines. In the absence of an indication for endotracheal intubation, a trial of high-flow nasal oxygen (HFNO), continuous positive airway pressure (CPAP), synchronized inspiratory positive airway pressure (SiPEP) or other non-invasive ventilation (NIV) technique may be considered for adults with COVID-19 and acute hypoxaemic respiratory failure failing standard oxygen therapy.
Questions or concerns? Please send these to covid19@samedical.org and we will endeavour to assist you.
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