Medical Aid Cover for COVID-19 in South Africa

medical aid cover

It’s essential to understand exactly what your medical aid covers for COVID-19 in South Africa.

Despite a recent fall in infection rates, COVID-19 is expected to be with us for some time.

New classification for COVID-19

In May 2020, COVID-19 was classified a Prescribed Minimum Benefit (PMB).

This has far-reaching consequences for medical aid members and the schemes.

What is a PMB?

A PMB is a healthcare condition that’s automatically eligible for a defined list of benefits.

Medical schemes in South Africa are legally obliged to cover the cost of the diagnosis, treatment and care relating to the condition, according to the regulations.

This means that all scheme members and their beneficiaries qualify for a certain level of cover.

This applies irrespective of individual benefit structures or whether there are funds in a member’s day-to-day savings accounts.

How do schemes pay for PMBs?

PMB benefits are paid from a scheme’s risk pool.

In order to mitigate the risk, schemes typically only cover the full cost of consultations, procedures and hospitalisation at network providers or designated service providers (DSPs).

The use of healthcare providers outside the network usually results in a payment gap that the member has to fund from his or her savings.

If the savings are depleted, the member pays from his or her pocket.

The implications of COVID-19 as a PMB

COVID-19 is defined as an acute respiratory disease.

The following PMB level of care is covered by all medical aid schemes in South Africa:

  • screening
  • clinically appropriate diagnostic tests
  • medical management, including hospitalisation and treatment of complications
  • rehabilitation.

COVID-19: what’s covered by medical aid schemes

Based on the PMB diagnostic and treatment pair listed for COVID-19, the scheme must pay for all medical consultations relating to the virus.

It must also cover the cost of the diagnostic test, the reverse transcription polymerase chain reactor test (RT-PCR).

This is only once a registered healthcare provider has screened the patient and given the go-ahead for the RT-PCR.

According to the PMB guidelines, only the cost of one test is covered in full, regardless of whether the patient tests positive or negative for COVID-19.

When a patient tests positive and requires hospitalisation, medical management and rehabilitation, the scheme is responsible for covering all the associated costs.

PMB-level medical management includes the use of high-flow nasal oxygen and ventilation.

The impact of COVID-19 on South African medical aid schemes

The virus has obviously led to a marked increase in claims, which has adversely affected solvency ratios.

On top of that, the economic downturn is playing havoc with the industry.

An increasing number of scheme members are giving up their memberships, considering downscaling to cheaper options or requesting payment holidays.

As a result, medical aid schemes are under pressure.

The sector will have to re-evaluate benefit structures and tailor options to the needs of members, taking demographics and disease profiles into account.

With pandemics expected to become more prevalent in the future, can you afford to be without medical aid?

How IFC can help

At IFC, we offer informed, objective advice about medical aid cover for COVID-19 in South Africa. We can assist you in joining the scheme that best suits your needs and budget. Contact us for more information or to discuss your needs.

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