Under new guidelines from the CMS, 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. As such, 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:
• 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.
Fedhealth 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 tests are still funded from day-to-day benefits, e.g. testing for pre-admission to hospital for a planned event, or having a test when already in hospital as a precautionary measure where the PUI criteria is not met, will not be funded from Risk benefits.
• Set an internal limit in the system with an exception process for those above the limit.
2. Cover for non-PUI members
If your test outcome is positive…
In the case of a positive diagnosis, your healthcare provider will prescribe the necessary care, depending on the severity of your symptoms. Fedhealth will cover out-of-hospital and/or in-hospital treatment as PMB from Risk benefits in line with the CMS and NICD guidelines.
If your test outcome is negative…
If the diagnosis is negative, the related tests will be covered from your Fedhealth benefits.
Any consultations with medical practitioners will be covered from the normal Scheme benefits available on your option. There’s no need to be tested more than once, but if you do this, it will also be covered in line with available option benefits.