Contact your medical scheme as soon as you can to ensure you benefit from the support it has put in place. Picture: Pexels/Cottonbro.
Contact your medical scheme as soon as you can to ensure you benefit from the support it has put in place. Picture: Pexels/Cottonbro.

Covid-19: What will my medical scheme pay for?

By Lifestyle Reporter Time of article published Dec 21, 2020

Share this article:

Many South Africans breathed a sigh of relief when the country seemed to be over the peak of the first wave of the Covid-19 pandemic.

However, the alarming recent resurgence in cases is a stark reminder we cannot afford to become complacent.

With the festive season, many of us will be attending family gatherings which could act as super-spreader events if we don’t stringently observe the now commonplace essential precautionary protocols like meticulous hand-washing, social distancing, wearing of masks and adequate ventilation. Outdoor family gatherings and other activities are much safer than indoor meetings.

Even with best practices in place, it is inevitable some of us will contract the virus and become ill. Given the healthcare costs associated with testing and treating, it is important for consumers to have peace of mind in knowing the disease is covered by their medical scheme and to understand the benefits which they are entitled to.

While these benefits may differ slightly, depending on your medical scheme plan, there are certain benefits which are covered by all schemes, regardless of your plan.

Lerato Mosiah, CEO of the Health Funders Association, an industry body for medical schemes and administrators, explained the medical schemes industry and their regulator were quick to respond to the pandemic to protect their members from unnecessary out of pocket expenditure.

“From as early as May, the Council for Medical Schemes (CMS) offered guidelines in alignment with the Medical Schemes Act.

“These guidelines were updated to ensure members are covered for screening, testing and treatment, in accordance with the Prescribed Minimum Benefit (PMB) regulations. Many schemes also offer cover above and beyond those as part of the scheme rules,” she said.

Mosiah explained certain Covid-19 benefits have been included in the PMB list, which meant these were available to all members, regardless of the plan they were on. She said the costs associated with these treatments would be paid by the scheme and not deducted from a member’s medical scheme savings account.

“As long as you are referred for a Covid-19 test by a medical practitioner, your medical scheme will cover the cost of the test, regardless of whether you test positive or not. This includes cases where you may merely have been exposed to the virus and after screening, be referred by your healthcare professional for testing. The cost of both screening and testing in such cases will be covered by your medical scheme.”

Depending on how severe your symptoms are, further tests, such as a chest X-ray, CT scan or other procedures may be necessary. These tests will also be covered by your scheme, regardless of which plan you are on, provided the medical practitioner has made the necessary referrals.

Mosiah said in many mild to moderate cases, home-based care would be sufficient to manage the symptoms. She said in such cases, patients could rest assured the necessary medications would be covered by the scheme, according to the scheme rules. These include antibiotics for secondary infections and treatments for chronic co-morbidities such as asthma, HIV or diabetes.

“It is important to make contact with your medical scheme as soon as you can to ensure you benefit from the support medical schemes have put in place to help you get the care you need.

“Where a patient is at a higher risk of developing complications associated with hypoxia, (low blood oxygen saturation levels) some schemes may also fund a pulse oximeter, a device for measuring the oxygen in your blood,” she said.

As with other PMB conditions, if you need to be admitted to hospital for treatment, these costs will be covered in full by your scheme. It is important to remember that if your medical scheme plan includes a network of hospitals or doctors, that you make use of these to avoid having to pay out of pocket.

Once an effective vaccine is available, it is likely this too will be covered by your scheme once it has been approved and included onto the National Essential Medicine List.

“As we enter the festive season and the Covid risks which that brings, we must realise the Covid-19 virus is part of our reality now, and will remain a prominent feature of the healthcare landscape for the foreseeable future, perhaps indefinitely.

“It is therefore important for medical schemes to continue to protect their members by providing for appropriate cover and for members to be assured they have the necessary cover should they contract the virus,” said Mosiah.

Share this article: