What you need to know about Covid-19 and your medical scheme

If your illness progresses, it may result in various complications such as pneumonia, renal failure and respiratory failure, all PMB-level of care

Covid-19 is highly contagious which makes going to the doctor when you are sick problematic, therefore some medical schemes are offering teleconsultations.

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

Covid-19 is highly contagious which makes going to the doctor when you are sick problematic. 

Some medical schemes are offering teleconsultations so that you can avoid a physical visit to the doctor. 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. 

However, remember that if it turns out you just have the flu, any consultation will only be covered to the extent that you have day-to-day benefits for this. 

Who pays for your diagnostic Covid-19 test?

Several medical schemes, such as Discovery Health, Profmed, the Government Employees Medical Scheme, Momentum Medical Scheme, Health Squared and Bonitas have announced that they will cover all costs related to treatment for members who test positive for the coronavirus.

For example, Discovery Health announced it was making a WHO Global Outbreak Benefit available to all its members. 

“Once your diagnosis is confirmed, you are covered for out-of-hospital costs for the related treatment from the scheme and not from your day-to-day benefits. In-hospital treatment related to Covid-19 for approved admissions is covered from the hospital benefit based on your chosen health plan,” Discovery Health told its members. 

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, the costs of a negative test will be for your own account. 

Members of schemes that have not announced special Covid-19 benefits may also find the cost of testing and treatment at home following a positive test are only covered from their day-to-day benefits. 

Dr Sipho Kabana, chief executive and registrar at the Council for Medical Schemes, says if your illness progresses, it may result in various complications such as pneumonia, renal failure and respiratory failure. These illnesses are prescribed minimum benefits (PMB) level of care and your scheme is obliged to cover the diagnostic tests and treatment of them. 

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 potential symptoms, as confirmed by a medical doctor.

How payment for a negative diagnostic test will be handled

COST OF A COVID-19 TEST

Lancet laboratories – R990
Pathcare – R995 

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.

 

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