The Council for Medical Schemes’ (CMS) governance structure, the Council, in concurrence with the Minister of Health, wishes to advise the industry of the following interventions, aimed at protecting the interests of members, in the wake of the ongoing coronavirus (COVID-19) pandemic and subsequent national lockdown from 26 March until 16 April 2020. 

1. COVID-19 is a Prescribed Minimum Benefit (PMB) condition 
All cases of COVID 19 are regarded as Prescribed Minimum Benefits (PMB) condition and should be funded in full in line with the current NICD guidelines as published. 

In line with clinical protocols and benefit guidelines, this should cover: 

  • All consultations;
  • All clinically appropriate diagnostic tests including Viral PCR;
  • All clinically appropriate medication; and
  • Costs of hospitalisation including all complications and rehabilitation.  

In accordance with the Medical Schemes Act of 1998, the use of designated service providers, clinical protocols and formularies should apply. This will apply for as long as the epidemic persists. 

2. Telemedicine 
The CMS encourages the usage and appropriate funding of Telehealth consultations in accordance with the updated notice on the Health Professions Council of South Africa (HPCSA) regulatory guidelines

3. Termination of membership due to non-payment 
In the spirit of social solidarity as outlined by the President during his address to the nation on Monday, 23 March 2020, the CMS requests that schemes investigate all disruptions to member contributions on a case by case basis and determine the merits thereof, prior to termination. 

4. Price and tariff negotiations 
The CMS supports price and tariff negotiations between key players aimed at improving access to care, prevention of exploitation of patients and cost reduction in the health sector as reflected in section 4 and 5 of Regulation No. 43114 published by the Ministry of Trade and Industry. Section 4 and 5 of the same regulation provides that at the request of the Department of Health, and subject to the oversight and guidance by the Department of Health, agreements must accordingly be approved and duly authorised by the Minister of Health. 

5. Medical Schemes, Administrators and Managed Care Organisations as support to essential services 
The CMS, Medical schemes and related entities will be regarded as support to essential services and therefore need to operate some functions during the lockdown including: 

  1. Industry regulation and member support [CMS]; 
  2. Membership maintenance [Schemes and Administrators]; 
  3. Contribution management – billing, receipting and reconciliation of monthly contributions [Schemes and Administrators]; 
  4. Claims management – pre-authorisation, claims receipt and adjudication, payment and reconciliation of claims. [Schemes, Administrators and MCOs]; 
  5. Financial management – more specifically cash flow and investment management [Schemes, Administrators and MCOs]; 
  6. Broker commission calculation and payment [Mainly Schemes and Administrators]; 
  7. Administration, financial and other systems employed maintenance and general IT support [Schemes, Administrators and MCOs]; and 
  8. Call centre function (albeit in a limited capacity – pre-authorisation, etc. would still be vital) [Schemes, Administrators and MCOs]. 
  1. CMS Operations 
    The CMS has decided to implement the following additional operational measures in response to the lockdown announced that will be in place between 26 March and 16 April 2020: 
  • All meetings and special projects at CMS are postponed indefinitely. This includes the release of the draft Section 59 Investigation report, the Low-Cost Benefit Option (LCBO) engagements and PMB review meetings.
  • All CMS personnel will remain at home during the lockdown period, except when required by the CMS to perform critical tasks, which cannot be carried out from home. 
  • The office will, therefore, operate with a skeleton staff during the lockdown and will only respond to:
    • Emergency clinical and administrative enquiries
    • Emergency Customer Contact Centre numbers:0861123267
    • Urgent regulatory matters 
    • Follow-ups on URGENT outstanding matters
    • Coronavirus related enquiries for support and guidance 

All statutory reporting should conform to set deadlines. The CMS will continue to monitor compliance with these statutory deadlines and will communicate changes in due course. 

The CMS will also be totally shut down for business between 10 and 13 April 2020 for the Easter Holidays. 

Finally, the CMS wishes to stress the importance of adhering to social distancing, and good hygiene practices including hand washing and sanitising as we confront this pandemic. 

Dr Sipho Kabane
Chief Executive & Registrar Council for Medical Schemes 

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