- The criteria for Covid-19 testing and medical aid benefits are important to understand should you require medical attention related to the virus.
- Each medical scheme has different criteria for testing, which can make members' decision making tricky should they require a test.
- Health24 outlines the Covid-19 testing criteria of the five biggest open medical schemes by membership.
As South Africa continues to navigate the second wave of Covid-19 infections, an increasing number of individuals will be seeking testing for the virus.
It is, therefore, important to understand what medical aids will cover, should testing, hospitalisation or treatment be required.
Covid-19 was mandated as a Prescribed Minimum Benefit (PMB) by the Council of Medical Schemes (CMS) as of 7 May 2020. These PMBs were defined benefits to ensure that all medical scheme members could access certain minimum health services, irrespective of the benefit option they have, according to the CMS website.
Although medical scheme benefits will differ from one another slightly, these regulations ensure medical scheme members, regardless of the plan they are on, are covered for Covid-19 screening, diagnostic tests, medication, hospitalisation and rehabilitation.
Health24 has outlined below what the five biggest open medical schemes by membership will cover, should you contract Covid-19:
Discovery Health Medical Scheme (DHMS) covers Covid-19 diagnostic Polymerase Chain Reaction (PCR) tests from the World Health Organisation (WHO) Outbreak Benefit.
This benefit ensures all members are covered for screening consultations, testing, management and supportive Covid-19 treatment.
DHMS members were covered for Covid-19 PCR diagnostic tests regardless of the outcome of the test, subject to meeting testing criteria and referral by a doctor, said Nthabiseng Chapeshamano, the senior reputation manager at DHMS.
If a DHMS member has not been referred for the Covid-19 test by a healthcare practitioner or does not meet the testing criteria (symptoms including a cough, sore throat, shortness of breath, loss of taste or smell), the member would be covered from their available day-to-day benefits.
Bonitas would pay for Covid-19 diagnostic tests from the risk-benefit, whether the result was positive or negative, said Lee Callokoppen, Principle Officer of Bonitas Medical Fund.
This provided the member, who took the test, was referred by a healthcare practitioner for a Covid-19 test because they either showed symptoms of Covid-19 or were in contact with an individual with the virus, Callokoppen added.
"The payment of the test in terms of a medical aid fund, boils down to the referral by the healthcare practitioner who will determine whether a test is necessary, and based on this, Bonitas will pay for the test regardless of whether it is negative or positive," he said.
When will Bonitas members not be covered for a Covid-19 test?
However, Bonitas would not pay for the Covid-19 test in instances where members were testing without cause, when they have not been referred, displayed no symptoms or were not in contact with a Covid-19 positive case, Callokoppen added.
Thus, as long as the Bonitas member had been deemed by the healthcare practitioner as requiring a test, then the fund would pay, regardless of the results, he said.
Momentum Medical Scheme covered Covid-19 testing if a member had tested positive for the virus, was presenting with symptoms associated with the virus with confirmation from their doctor, or if the member had been in direct contact with a person who had tested positive for Covid-19 with a doctor's referral note, according to Damian McHugh, the executive head of marketing at Momentum Health Solutions.
"In all instances, members of Momentum Medical Scheme are required to contact our call centre prior to being tested to understand how the test will be covered based on their plan type, as well as what process they are required to follow," said McHugh.
Momentum Medical Scheme would not cover the cost of a follow-up Covid-19 test unless the member had a referral from their doctor stating they were still presenting with symptoms associated with the virus, he added.
What if the Covid-19 test result is negative?
Similarly, if a member tested negative for Covid-19, Momentum Medical Scheme covered the cost of the test provided they were in direct contact with a confirmed case, if they were presenting symptoms associated with the virus and had a referral letter from their doctor and contacted the scheme for authorisation, McHugh said.
Bestmed will fund Covid-19 screening consultations and pathology tests as a PMB from the scheme risk-benefit whether or not the test result is positive or negative.
This provided members show symptoms of Covid-19 or were in contact with a confirmed case and if a member was referred for the test by a healthcare worker.
What if members do not have a doctors' referral?
"If a member is asymptomatic and is not referred by a healthcare worker, consultations and pathology tests will be paid from the relevant scheme benefits according to their option rules and benefit availability," said Andrea Vermaak, the communications specialist at Bestmed.
If a Bestmed client chose to go for a follow-up test, the scheme might ask for a motivation or pay from risk of savings.
"If the first test was negative, and the second test positive, it will be paid from risk, if the member was referred by a healthcare practitioner," she added.
The Medihelp website stated the scheme provided both comprehensive in- and out-of-hospital cover on all benefit options for claims received for Covid-19 irrespective of the result for the test according to the clinical criteria for testing.
Additionally, Medihelp will cover benefits for telephonic and video consultations with general practitioners or specialists at 100% of the Medihelp tariff. The website stated this was subject to members' available day-to-day benefits.
*Quotes related to Bonitas were previously attributed to Kathy Malherbe, Bonitas communications consultant.