Covid-19: What your medical aid will and won’t cover

One of the big issues around Covid-19 worldwide, has been testing. Cost has been a huge factor, especially for cash strapped South Africans. Those with medical aid probably hope they are covered, but it is not that simple.

After the first confirmed case of Covid-19 in South Africa, the Council for Medical Schemes (CMS) released a statement saying most medical health insurance providers would pay for tests for the novel coronavirus.  

Discovery Health, Momentum Health, Profmed, Fedhealth, and GEMS, have all indicated their members would be covered for coronavirus testing.

Confirmed cases of Covid-19 are covered for:

• Diagnostic testing;
• Consultations; and
• Defined supportive treatment and medicines

It is important to note that full coverage will only be implemented should you test positive for the virus. 

Testing and treatment will not come out of your medical savings account. 

If the test comes back negative and you do not have the virus, then the cost will come from your medical savings. 

Private testing can be expensive. Currently, Lancet is the only lab offering private Covid-19 testing, for an estimated R1,431. 

The CMS recommends that all testing for the coronavirus be referred to state laboratories and not private labs, as advised by the Department of Health.

Discovery Health has launched the WHO Global Outbreak Benefit for all of its health plans. 

The benefit ensures members have access to the out-of-hospital management and appropriate supportive treatment which meet the scheme’s clinical protocols and entry criteria. 

As the virus progresses, it may result in various complications, such as pneumonia and respiratory failure. Should this happen, it becomes treated as a Prescribed Minimum Benefit (PMB).

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. 

PMBs are a feature of the Medical Schemes Act of 1998, and medical schemes have to cover the costs related to the diagnosis, treatment and care.

In a recent statement, Dr Sipho Kabane, the chief executive and registrar of CMS, said that “all medical schemes are required by law to pay for the diagnosis, treatment and care costs of PMB conditions in full, irrespective of plan type or option. 

“They are not allowed to fund PMB conditions from a member’s Medical Savings Account, as this is not in line with the PMB Regulations.”

According to the CMS, if you have an uncomplicated infection with no PMB-eligible conditions, then the medical scheme may fund all health care costs as per scheme rules.

Because individuals can spread the virus without showing any symptoms, Kabane said that “we [the CMS] encourage all who have travelled to areas with confirmed cases, or have come into close contact with someone who has travelled, and thereafter experience flu-like symptoms and a fever, to seek immediate medical attention.”

Medical scheme members are encouraged to contact their medical schemes on their benefit option entitlements if they experience flu-like symptoms. 

If you are showing symptoms such as a cough, fever or have difficulty breathing, arrange for a virtual or telephonic consultation with your healthcare provider. MC