The Council for Medical Schemes has confirmed that COVID-19 falls under the prescribed minimum benefits as defined in the Medical Schemes Act.
According to Neil Kirby, Director and Head of the Healthcare & Life Sciences practice at Werksmans Attorneys, the effect of the amendment is that for all medical scheme members, regardless of what plan they are on, in the event that they contract COVID-19 and subsequently suffer respiratory illness due to COVID-19, the medical scheme is obliged to cover all costs associated with treatment complications associated with the respiratory illness.
“Where it may have previously been unclear whether or not medical schemes would cover the costs for the treatment of COVID-19 for members on lower plans, leaving the responsibility for payment on the State, the amendment, arguably, relieves certain financial pressure on the Department of Health in so far as the State is now obliged only to cover the costs of citizens who are not covered by medical schemes,” says Kirby.
Testing of a member with no symptoms and who is negative will be “funded according to scheme rules”, which appears to imply that such testing will be funded from benefits available to the member other than prescribed minimum benefits.
The PMB cover will not relate to any follow-up treatment of a person with symptoms who tests negative for COVID-19.
Kirby says the CMS has also recommended that rather than patients being seen at doctors’ rooms, telehealth be delivered through online platforms and be reimbursed as PMB level of care in line with the latest Health Professions Council of South Africa recommendations.
Related: Premium relief on medical shemes unlikely
This article first appeared in City Press.
Not impressed with Discovery Health. My husband had to go into hospital for surgery in April.The surgery was authorized by Discovery, but when he did his preadminisreation at the hospital 48 hours before the surgery, the hospital insisted on doing a COVID 19 test. I would have assumed this test would have been covered along with all the other pathology tests done in the hospital during his stay under his hospital benefits, but Discovry said NO it comes out of MSA, which is wrong if it is a prerequisite before the hospital would admit him. Discovery needs to adjust their policy to cover this test if it is a prerequisite of all hospitals now!
There seems to be a disagreement between schemes and hospitals around the need for COVID testing. Apparently you could be infected and still show a false negative if it is early days. Protocol is to act as if each patient is infected.
Schemes don’t pay for processes they deem unnecessary.
I suspect there are discussions going on around this…