A NURSE wearing protective gear at the quarantine wards of the Tygerberg Hospital in Cape Town where coronavirus patients will be treated. Ian Landsberg African News Agency (ANA)
A NURSE wearing protective gear at the quarantine wards of the Tygerberg Hospital in Cape Town where coronavirus patients will be treated. Ian Landsberg African News Agency (ANA)

Will you be covered if you test positive for Covid-19?

By GTC Healthcare Time of article published Mar 18, 2020

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People who contract Covid-19 who are under the age of 80 and do not have any pre-existing conditions - such as cardiovascular disease, diabetes, chronic respiratory disease, hypertension or cancer - are most likely to experience only flu-like symptoms. However, those who are over 80, or individuals with pre-existing conditions, are at much greater risk.

To prepare yourself and your family for possible infection of the virus, Jill Larkan, the head of healthcare consulting at wealth and financial advisory business GTC, says there are a few important steps to follow.

“Should you experience a combination of the following symptoms, it is important to record these and also to note when these symptoms first began: fever, sore throat, dry cough or breathing difficulties,” says Larkan.

“The next important step is to call your local doctor or general practitioner (GP) to explain the symptoms and to request advice about the best way to proceed. It is not recommended that you go into the doctor’s consulting rooms because if you do have the virus, it is vital that the virus does not spread to any of the staff or other patients in the doctor’s waiting room.”

Larkan says that doctors will provide clear guidelines about how to proceed in terms of the testing procedures.

If you don’t have a doctor you can call, there is a national Department of Health Coronavirus Hotline number (0800029999), or you can contact the National Institute for Communicable Diseases on 0828839920 for testing purposes. “These hotlines were established for concerned citizens and have been specifically set up to deal with the outbreak.”

Positive or negative

Larkan says that most medical scheme plans have different levels of cover, depending on whether you have tested positive for Covid-19 or negative for the virus.

“Even though some medical schemes have confirmed that they will cover out-of-hospital costs related to medical aid members who have tested positive for Covid-19, if your test result is negative, most medical aids have confirmed that you will need to rely on the existing benefits of your selected plan, to bear the costs of testing and diagnosis,” says Larkan.

Dr Sipho Kabana, chief executive and registrar at the Council for Medical Schemes (CMS), confirmed in a recent press release that, as the regulator, the CMS is committed to ensuring that there is effective cover for members who suffer from the coronavirus - including complications.

“We encourage medical schemes to provide comprehensive cover for all confirmed cases, in the interest of public health,” Kabane said.

“As the virus progresses, it may result in various complications, such as pneumonia and respiratory failure, which should be treated as prescribed minimum benefit (PMB) level of care,” said Kabane.

In cases of uncomplicated infection (thus even if you have tested positive), where there are no PMB-eligible conditions, the medical scheme may fund all healthcare costs per the scheme rules.

If you are not positive when tested for Sars-CoV-2 and - based on Kabane’s explanation, even if you are positive, without any complications - Larkan says your consultations, tests and medicine could be handled by your medical scheme, as follows:

* Entry-level plans, which usually have network doctors available for consultation and provide formulary medication for condition treatment. Your diagnosis will likely be covered by your medical scheme.

* Hospital plans, which usually do not cater for out-of-hospital treatment. The cost of diagnosis and testing will be for your own account.

* Saver plans usually provide an allocated savings amount for out-of-hospital treatment for the year, to cover consultation and testing. If this savings account has not already been exhausted, you should have your testing costs covered from your savings account. If your savings allocation has already been exhausted, you will be responsible for the costs incurred.

* Comprehensive plans usually cater for out-of-hospital diagnoses and treatment via, first, a savings account, and, second, from an above-threshold benefit account. These two funding accounts are separated by a self-payment gap that comes into effect once the savings allocation is exhausted, and before a member can enter the above-threshold benefit account.

“Payment depends on where you are on the continuum of funding. If you are either in the savings account or already in the above-threshold benefit account, your testing costs are likely to be funded by your medical aid,” says Larkan. “If, however, you find yourself within the self-payment gap, you will be responsible for the costs yourself.”

* Traditional plans usually provide a prescribed benefit for GP visits and another benefit for medication. If these benefits have not already been exhausted, your diagnosis and testing costs should be covered by your medical scheme.

Larkan says the main medical scheme member should share all information with every family member regarding the specific medical scheme plan they belong to, so that if the main member falls ill or is unavailable, everyone knows the plan type and what extent of cover they can expect in the event of infection.

“Know how your medical aid will treat you if you test positive for Covid-19. Many medical aids have released additional benefits to all their members, providing assurances and confirming that additional out-of-hospital benefits will be available for testing, diagnosis and treatment,” she says. 


Larkan  says the other important things you should know are:

* Know and list your medical scheme name, plan type (for example, a hospital plan or a saver plan), your membership number and call centre telephone number. This may be required for pre-authorisation or additional information about networks, hospitals, ambulance services, doctors, pharmacies and medicines.

* Know how your out-of-hospital benefits will be provided. Does your medical scheme have a savings account, for example? What is the balance in the account?

* Know whether your medical scheme restricts doctor visits to specific networks of doctors, or even to a specifically listed family doctor. “Make sure that your family is aware of the doctor’s name and contact telephone number,” Larkan says.

* Know how prescribed medicines will be paid from your scheme, particularly if you are on a hospital-only scheme, or if your savings account balance is zero.

* Know whether your scheme allows for the purchase of over-the-counter medication from the pharmacy, and if so, make sure you know whether there are any restrictions. “Some medical aids limit this benefit to a rand-value maximum, while others provide the benefit up to the balance of the savings account, or even up to a rand sub-limit,” says Larkan.

“Getting the right care and attention if you have the coronavirus is essential. Don’t let a lack of information prevent you or your family members from getting the medical assistance that is needed as quickly as possible.”


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