All COVID-19 tests to be covered from Risk for PUIs

The Council for Medical Schemes (CMS) has issued revised guidelines for medical schemes with regards to the payment of COVID-19 tests. Under these new guidelines, schemes must pay for all COVID-19 tests, whether they are positive or negative, from Risk and not from members’ day-to-day benefits if the member is a ‘person under investigation’ or PUI.

The funding stance of COVID-19 pathology tests has been updated and signed off by the Fedhealth Board of Trustees to be in line with the revised CMS circular. All claims from 1 June 2020 are being reprocessed to pay in line with the new stance.

Who qualifies as a PUI?
A suspected COVID-19 case includes any person presenting with an acute (+14 days) respiratory tract infection or other clinical illness compatible with COVID-19, or an asymptomatic person who is a close contact to a confirmed case.

In the context of COVID-19, the key respiratory syndrome consists of any of:

• Cough
• Sore Throat
• Shortness of breath
• Anosmia (loss of smell) or dysgeusia (distortion of the sense of taste)

… with or without other symptoms (which may include fever, weakness, myalgia or diarrhoea.

  • Note: Although asymptomatic close contacts are classified as suspected cases, they should not routinely be tested.

Important: The member’s treating doctor will determine if the patient is a PUI or not, in line with the NICD guidelines, and the ICD 10 code will determine how the Scheme pays for it.

Fed health is following these revised funding guidelines as set out by the CMS. This means Fedhealth will:
• Fund COVID-19 tests in line with the revised guidelines to pay from Risk for all PUIs regardless of the test result.
• All non-PUI claims and tests are still funded from day-to-day and the Scheme won’t consider them from Risk. E.g. if a member just wants to have an operation done and doesn’t meet the criteria for a true PUI, it will not be funded from Risk.
• Set an internal limit in the system with an exception process for those above the limit.

We hope that this puts clients’ minds at ease.

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