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Prescribed Minimum Benefits: what you need to know about medical cover during the COVID-19 pandemic

16 July 2020 Tony Singleton, CEO at Turnberry Management Risk Solutions
Tony Singleton, CEO at Turnberry Management Risk Solutions

Tony Singleton, CEO at Turnberry Management Risk Solutions

With lockdown easing, people are heading back to work and school which means a sharp rise in COVID-19 infections is inevitable. More people are going to need to test for the virus as the rate of infection increases.

It is therefore important to understand exactly how medical schemes will cover COVID-19 testing, hospitalisation and treatment in order to avoid unexpected medical expense shortfalls. Couple this with many people experiencing financial hardships during this time and one must also try and stretch the benefits that their medical scheme has to offer. So, what should people be looking out for?

COVID-19 testing is a Prescribed Minimum Benefit (PMB)
The Council for Medical Schemes has mandated medical aids to consider Covid-19 testing a Prescribed Minimum Benefit. All registered medical schemes in South Africa need to provide PMBs on all plans offered to members, regardless of plan type. In terms of the Medical Schemes Act, these PMBs are a set of defined benefits that relate to 270 categorised conditions that all medical scheme members can utilise.

What is COVID-19 and what is covered by PMB?
The condition “COVID-19” is defined as “an acute respiratory illness caused by a novel coronavirus”; and annexure A of the Medical Schemes Act (which lists PMBs) has been amended by the Minister of Health to include this new respiratory illness.

Along with these 270 conditions that the medical schemes are obliged to fund from the risk benefit, they are able to curb their risk by requiring members to utilise Designated Service Providers (DSPs) only. By using providers in the medical scheme’s network, members can rest assured that their scheme will cover that in full. Should a patient choose not to use a DSP, then the medical scheme is only required to pay in line with medical aid rates.

There are certain instances in which patients can make use of a non-DSP, but these extend to life-threatening emergencies.

What is and is not covered?
According to COVID-19 PMB guidelines, the recommended test at PMB level of care is the Reverse Transcription Polymerase Chain Reaction (RT-PCR) test. In a situation where a person is to be treated out of hospital and they present with symptoms, they must be screened by a healthcare provider who deems the test necessary due to the suspicion that the patient may have COVID-19. Regardless of test results, as long as the member was screened by a healthcare professional and was deemed necessary by a medical professional (who is a DSP) and the RT-PCR test is used, it must be funded from the medical aid’s risk benefit as a PMB. Where the person tests negative, any follow up care is not covered. In the case of a positive test, hospitalisation (including ventilation) and medical management of the patient’s condition thereafter would be funded from the risk benefit as a PMB and not from the members day-to-day benefits.

Where patients are to be admitted to hospital for other reasons (such as elective surgical procedures) they may be requested to undergo a COVID-19. test beforehand. In these situations, it is not PMB level of care therefore medical aids do not have to fund the test from the risk benefit. Here, the cost of testing would most likely come from the members day-to-day benefit or be self-funded. Should a person voluntarily choose to make use of a non-DSP then, that member is likely to be exposed to a medical expense shortfall for the in-hospital treatment.

It is also important to note that while the focus of many is on COVID-19 it is not the only reason why people are being admitted to hospital during this time period. People are still admitted to hospital for essential treatment such as heart attacks, fractures, cancer treatment, organ transplants.

Is gap cover going to help with COVID-19 medical scheme shortfalls?
Many families are facing financial hardship and Gap Cover is the smart way of protecting you and your family from costly in-hospital medical expense shortfalls. This is the difference between what your private healthcare providers charge and the rate your medical aid pays for in-hospital treatment. Moreover, hospital admission may not always be as a result of COVID-19, however, with the current times we are in, people need to be prepared for out of pocket medical expense shortfalls - regardless. It is also important for consumers to understand their medical scheme coverage and even more importantly the PMB benefits for COVID-19. So, contact your financial advisor today and ensure your family is ‘in the know’.

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