COVID-19 now added as a prescribed minimum benefit (PMB)

Medical Aid schemes yet to quantify impact of pandemic

No one could have predicted the scale of the Covid-19 pandemic, least of all medical schemes. In the current climate, the private healthcare industry is in a precarious position given the impact of the pandemic on members and the domino effect on claims.

This is according to Clayton Samsodien, CEO of newly formed Phoenix Financial Services Group (PFSG), a niche consumer-orientated financial service provider born during the pandemic.

He adds, “Initially there were no guidelines from the Council for Medical Schemes and each medical scheme applied benefits for COVID-19 according to the rules of the medical scheme and the particular options. In June we saw a significant increase in claims related to Covid-19 testing as prescribed minimum benefit (PMB) guidelines became known to medical schemes and members.”

Covid-19 has now been added as a prescribed minimum benefit (PMB) and most medical schemes will cover the following:
• Screening consultation in a network
• Screening tests after a risk assessment
• Pathology and X-rays for patients who test positive
• In-hospital treatment with a designated service provider (DSP) as indicated by a scheme
• Supportive treatment and home monitoring devices, accommodation, and isolation facilities.

PMBs are the minimum health services that medical schemes must provide to members of a medical scheme. According to the Medical Schemes Act, PMBs are covered in relation to the cost, diagnoses, treatment, and care of any emergency medical condition that is life-threatening, a limited set of 270 medical conditions and 27 chronic conditions.

Members will benefit from this development as they can now access treatment for Covid-19 as part of PMBs. For members with comorbidities such as diabetes and hypertension, these are already covered. Most medical schemes offer disease management programs for members with diabetes, HIV, cancer, and other diseases. Samsodien advises members who suffer from these conditions to register for the chronic disease benefit and disease management programs offered by their respective schemes to ensure the most appropriate management of the health condition and best outcomes.

At the onset of the virus locally, medical schemes benefited as elective procedures were deferred to make way for the treatment of Covid-19. Says Samsodien, “In April, elective procedures were fairly non- existent and in May and June about half of scheme members were tested for Covid-19 prior or during admission. The hard lockdown also contributed to curbing the spread of other contagions leading to a reduction in claiming patterns as members simply did not visit healthcare professionals. The initial impact on medical schemes was claims related to testing which is considered a low cost but high volume.”

Notwithstanding the high prevalence of HIV and TB, our fairly young age profile as a country and moderate risk of comorbidities helped to reduce the overall impact of the virus thus far. However, the highest risk areas remain obesity and population density in urban areas.

South Africa was fortunate in that as a country, we had time to prepare and learn from the experiences of countries that were affected fairly early on. Government, health care experts, and healthcare providers both public and private including medical aid schemes used information and learnings from countries where the first outbreaks occurred to ultimately reduce the impact of the virus on the general public.

“According to the current numbers we are seeing a decrease in local transmissions. This does not mean we are out of the woods just yet. A major positive is the change in seasons as we exit winter with the usual winter illnesses reduce, thereby increasing our immune systems. We need to continue to wear face masks, wash our hands regularly and practice social distancing otherwise we run the real risk of a second wave which will likely be more deadly and have a much more conspicuous impact on the country as a whole,” concludes Samsodien.