• The Council for Medical Schemes published new guidelines on what constitutes prescribed minimum benefits for Covid-19, defining when medical aids must pay – and when they don't necessarily have to.
  • This version of the rules specifically exclude testing for newborns of mothers with confirmed cases of Covid-19 as a routine precaution.
  • Medical schemes already don't have to pay if a hospital demands a pre-admission test, and it turns out to be negative.
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South African medical schemes don't have to automatically pay for Covid-19 tests of babies born to mothers known to have the disease, the Council for Medical Schemes (CMS) said on Thursday.

The explicit exclusion is part of a routine update of rules for medical schemes in the third version of the CMS' PMB definition guideline for Covid-19.

PMBs, or Prescribed Minimum Benefits, must be paid for by every medical scheme for every member, regardless of the type of plan they have, the amount they pay every month, or how many claims they have had over any given time period.

Covid-19 testing and treatment, broadly speaking, as well as any vaccine for the coronavirus that may be developed, are among such prescribed minimum benefits.

But there is also a growing list of specific exclusions, which will make payment for tests subject to scheme rules. Such rules can call for payment from medical savings accounts, limit benefits, pay only up to a certain amount, or use other mechanisms to manage the cost of healthcare.

"Babies in good health, who are born from a Covid-19 infected mother do not need a Covid-19 test, and such testing is therefore not PMB level of care," the CMS said in its updated document on Thursday.

Testing is only required for "unwell or symptomatic babies", it said, "if the case definition is met".

Testing is also indicated for "any neonate presenting with acute respiratory symptoms".

In another new rule, "testing of asymptomatic people returning to work" is now also specifically excluded from PMB.

Guidelines now also explicitly say that asymptomatic close contacts of people with Covid-19 should not be routinely tested, except in specific circumstances, such as in care homes.

Under a previous version of the rules, routine pre-admission testing "for asymptomatic patients which turns out negative" is already subject to scheme rules.

(Compiled by Phillip de Wet)

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