Understanding Prescribed Minimum Benefits- COVID-19

Prescribed Minimum Benefits (PMBs) are a set of defined benefits to ensure that all medical scheme members have access to certain minimum health services, regardless of the benefit option they have selected. The aim is to provide people with continuous care to improve their health and well-being and to make healthcare more affordable.

PMBs are a feature of the Medical Schemes Act, in terms of which medical schemes have to cover the costs related to the diagnosis, treatment and care of:

  • any emergency medical condition;
  • a limited set of 271 medical conditions (defined in the Diagnosis Treatment Pairs); and
  • 26 chronic conditions (defined in the Chronic Disease List).

For more you can see Council for Medical Schemes.

Having recently had COVID-19 I have learnt a bit about navigating PMBs, and to be honest it requires a level of understanding of medical aids. For me I am on a hospital plan. I am prepared to cover out of hospital benefits. I made this decision because mostly I am healthy and some of the benefits I use were not covered.

When I got COVID-19 I did fortunately know that it was a PMB, and that some of the tests should be covered (even if they were out of hospital). There is some admin on my part required along the way.

Every medical diagnosis carries an ICD-10 code (which stands for international classification of diseases). The ICD-10 coding is a system used by healthcare providers to classify and code all diagnoses, symptoms and procedures. ICD-10 codes tell the story of each patient encounter. It identifies incidence of disease, helps track health data. The ICD-10 codes for Covid were added in March 2020. So the list is constantly updated.

I was referred for a test, but until I got the test back my diagnosis is not verified. My initial reason for testing is sinusitis and it is coded as such (J01.90 acute sinusitis unspecified). When my test result comes back positive the ICD-10 code should be updated to indicate I have COVID-19, which would be U07.10. This is what I learnt:

  • The laboratory cannot update the ICD-10 code. In hindsight this makes sense as many laboratory tests confirm clinical findings. This needs to be done by the doctor, or  in this instance I needed to send my test result to the medical aid (apparently some medical aids do let people know this, but mine did not). I only knew to query non payment of my test because I was aware COVID-19 was a PMB.
  • Once we got through that admin it opened up a basket of care. I needed further blood tests, some of these were then covered by my scheme, and so I was able to claim back for my expenses. I was also able to go back and resubmit my claim for medication and some of this too was covered.
  • If my test had been negative, then the medical aid would not have had to fund the cost of the test or some of my treatment
  • To find out minimum care for COVID-19 you can click here

When you get accounts from healthcare providers it is important to check the ICD-10 code. It may also be that if your diagnosis changed, based on further testing, you may need to have your ICD-10 code updated. You may then also need to inform the medical aid in order for them to pay for the test and any other medical treatment which may be covered under the PMB. The scheme and plan you are on may not open up the Rolls Royce of treatment, but it will open up minimum care. There are many other conditions covered under PMB legislation, it is worth understanding it and seeing if some of your conditions are covered (some other common conditions are hypertension, diabetes and  fractures)

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