Medical schemes will only cover the costs of your coronavirus test if it comes back positive. Picture: 123RF/MICROGEN
Medical schemes will only cover the costs of your coronavirus test if it comes back positive. Picture: 123RF/MICROGEN

The Council for Medical Schemes (CMS) has confirmed that, with immediate effect, all positive cases of Covid-19 should be treated as a Prescribed Minimum Benefits (PMB) condition.

This means that if you test positive, your medical scheme will pay for all treatment out of its risk pool and not from your savings or day-to-day benefits.

However, the costs of the test are only covered if your test comes back positive — many thousands of South Africans have been tested but only a few hundred have tested positive. If your test is negative and you went to a private pathology lab to do it, the cost will only be covered if you have day-to-day benefits.

Many members only enjoy day-to-day benefits through a medical savings account. When this is depleted or you don't have access to a medical savings account, the costs of a negative test will have to come from your own pocket.

Health Squared’s principal officer David Smith says the scheme will cover the testing costs for all members “at risk” for Covid-19, irrespective of the results. So far it is the only scheme doing this.

You are defined as “at risk” if you:

  • Have returned from a high-risk area within the last 14 days; 
  • Have been in contact with a confirmed Covid-19 coronavirus patient, and
  • Are showing symptoms, as confirmed by a medical doctor.

Silindubuhle Mnqeta, customer relations officer at the CMS, said the decision to cover all Covid-19 cases under PMB benefits was taken after it was declared a pandemic and a national disaster.

Damian McHugh, executive head of growth and marketing at Momentum Health, said the company had already been paying for all treatment of positive Covid-19 patients from risk.

“In light of the social challenges in SA, this was a decision we had already made so the CMS circular makes no material difference to our policy around Covid-19,” he told BusinessLIVE.

This means that if you test positive, your medical scheme will pay in full for:

  • All consultations;
  • All clinically appropriate diagnostic tests;
  • All clinically appropriate medication; and
  • The costs of hospitalisation including all complications and rehabilitation.

McHugh noted that most cases of Covid-19 were mild and were typically given treatment such as pain medication or cough relief medication and sent home to self-isolate until they recovered. This treatment will now also be paid for as a PMB.

Covid-19 is highly contagious and since going to the doctor when you are sick is problematic, some medical schemes are offering teleconsultations. But remember that this does not necessarily mean your scheme will pay for your consultation if it turns out you have a more mundane variety of flu.

Discovery Health Medical Scheme, for example, offers you DrConnect, while Profmed uses Medici. These are apps that put you in contact with a doctor virtually.

For example, through DrConnect you can have a consultation with a participating doctor and the app will show you if doctors you have seen in the last 12 months are available for voice, video or text consultations.

The app also allows you to search for answers to common medical questions.

The World Economic Forum advises that if you have tested positive for Covid-19, you can stay in your home with other family members but must remain in a separate room with a window so that you have access to ventilation.

Mnqeta says the PMB benefit for Covid-19 will apply for as long as the pandemic persists.

By Friday morning, the number of positive Covid-19 cases in SA had breached 1,000 and there had been two Covid-19 deaths, both in the Western Cape.

How payment for a negative diagnostic test will be handled

Jill Larkan, head of healthcare consulting at wealth and financial advisory business GTC, says this is how most medical schemes will handle payments for negative diagnostic tests:

  • Entry-level plans: These plans usually use a network of doctors and if you use the network, your test is likely to be covered as a day-to-day benefit by your medical scheme.
  • Hospital plans: You are only covered for treatment administered in hospital (not the emergency room) and the PMBs, which means you must pay for your test.
  • Saver plans: You have an allocated savings amount for “out-of-hospital” treatment. If you still have money in your savings account, this will cover your testing costs, but if your savings allocation has already been exhausted, then you must pay.
  • Comprehensive plans: These plans usually cater for “out-of-hospital” diagnoses and treatment via your savings account first and then from an “above threshold benefit” account. These two funding accounts are separated by a ‘self-payment gap’ which comes into effect once you have used all your savings and before you can start using the “above threshold benefit”. If you fall in the self-funding gap, you must pay for the test.
  • Traditional plans: These plans usually provide specified benefits for GP visits, medicines and tests. If these benefits are not exhausted, your testing costs could be covered by your medical scheme.