The answer to this question changed on Friday the 22nd of May 2020 when the Minister of Health published the required regulations to make COVID19 a Prescribed Minimum Benefit (PMB). However, payment does still to some extent, depend on which medical aid you are on and if admission to hospital for the condition is seen as an emergency or not.
Until the Minister clarified the situation by publishing the new regulations it was not clear how medical aids would pay for the condition with considerable variation between medical aids. It is still not clear how medical aids will pay for costs incurred before the 22nd of May. Early in the pandemic, the Council for Medical Schemes (CMS) stated, through the media, that the condition is a PMB and will be viewed as such by the regulator. This statement was not backed up by changes or insertions into the regulations which underpin the PMBs, until the recent changes. It seemed to be more of a statement of intent than a giving effect to what the CMS wanted to see.
Now that COVID-19 is a PMB the payment for tests becomes subject to one of the key shortcomings of the current PMB regulations. A medical aid is only required to pay in full (diagnosis and treatment) for a PMB when it is actually diagnosed. The problem is that people don’t go to the doctor with a diagnosis, they go with a set of symptoms. It is possible to rack up extensive bills for various tests and consultations without knowing whether the costs will be covered as a PMB or not. If the diagnosis comes back as a non-PMB then the medical scheme member could be liable for the costs involved in reaching the diagnosis.
In the case of COVID-19, many people are being tested and getting negative results back. At the time of writing, 95% of people tested are negative. Your medical aid may well not pay for the test with a negative result.
The problem with this is that one cannot simply go for a COVID-19 test, you have to meet government determined criteria in a screening process to warrant testing. And, once you’ve been identified for testing by the screening process, you cannot decline to have the test. This leaves 95% of medical aid members who have tested negative with the risk that they may have to pay for their test (despite the fact that COVID-19 is now a PMB) even though having the test was a public health necessity and couldn’t be avoided.
Prior to the 22nd of May, various medical aids had differing (and evolving) policies on this. The largest medical aid (Discovery Health Medical Scheme) changed its policy on Wednesday 20 May 2020 so that it would then pay for tests no matter what the result is. Up until that point, it was not paying for negative test results. Polmed had sent communications to healthcare providers indicating that they will view COVID-19 as a PMB as well as pay for all tests. At the other end of the spectrum was Fedhealth which had communicated that it would only apply the PMB regulations to COVID-19 when it became pneumonia – which is regulated as a PMB. Should a Fedhealth member have got COVID-19 and was ill, but not developed pneumonia then their costs would have been handled by the medical aid just like any other non-PMB condition.
Each medical aid is likely to apply their various rules around using Designated Service Providers (DSPs) and the like to determine payment for COVID-19 now that it is a PMB. This raises the key question of whether admissions to a hospital for COVID-19 are emergencies admission or not. Also, is there space in the hospital that your medical aid requires you to use? If it is an emergency and/or there is no space in the medical aid’s DSP hospital then the medical aid is required to pay for that admission in full.
If you are having difficulties with your medical aid you can contact us to see how we can help you.
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