The COVID-19 Vaccine Is on the Prescribed Minimum Benefit List. What Does It Mean for You?

What does the COVID-19 vaccine's listing as a Prescribed Minimum Benefit mean for you as a medical scheme member?

Your medical aid will pay for your vaccine

Almost as soon as COVID-19 arrived in South Africa, the Council for Medical Schemes (CMS) listed its treatment as a Prescribed Minimum Benefit (PMB) for medical scheme members. Basically, all medical schemes, medical aid and hospital plans have had to cover COVID-19 and all its various treatments since then. And this includes vaccines!

The South African government aims to vaccinate at least 67% of the population against COVID-19 (by end of 2021) to achieve herd immunity. But there have been many questions about the roll-out. Some have asked: 'Does having medical aid mean I will be prioritised for the jab over non-members?'

The guideline for COVID-19 treatment includes approved COVID-19 vaccines, which means that if you're a medical scheme member, your scheme needs to pay for your vaccination injection.

But medical aid members won't be 'prioritised' for the COVID-19 vaccine

Dr Sipho Kabane, registrar of the CMS, warns that the sorting of who gets the vaccine first is done at a national level for both public and private healthcare sectors – including members and beneficiaries of medical schemes.

This means that your medical aid does not get to choose when you get the vaccine. That's out of their hands.

On the other hand, COVID-19-related screening, diagnostic tests, medication, hospitalisation, treatment for complications and rehabilitation are all PMB levels of care for medical scheme members.

Treatment after recovery

Dr Kabane says, 'Schemes are expected to cover the costs of PMB conditions, including COVID-19 and medical emergencies, in full. These costs are subject to the use of evidence-based and cost-effective clinical protocols, medicine formularies and designated service providers as published by medical schemes and administrators.'

Chest physiotherapy and other rehabilitative and palliative care modalities, such as psychotherapy, are also PMB levels of care for confirmed COVID-19 cases, if you are referred by your treating provider.

Your medical aid isn't a 'guarantee'

The South African health system has been placed under severe strain by the second wave of coronavirus infection, with a shortage of beds and oxygen leading to a crisis in both public and private hospitals. All COVID-19 patients are treated equally when it comes to hospital admissions and allocation of beds for treatment.

Being a member of a medical scheme doesn't guarantee you a bed in a hospital the same way that membership doesn't guarantee you a dose of the vaccine. However, since treatment is a PMB, it does mean that if you're prescribed treatment, the cost will be covered by your medical scheme.

The boundaries of PMBs

'Elements like a repeat RT-PCR test to ensure that the patient is no longer positive will be funded at the discretion of the scheme based on the scheme rules. They are therefore not a PMB entitlement,' according to Dr Kabane.

'There is currently little or no evidence that people who have recovered from COVID-19, and have antibodies, are protected from reinfection. As such, the number of RT-PCR tests per member should not be capped for a member who presents with COVID-19 symptoms, and meets the case definition,' Kabane says.

Serum antibody testing is also not covered as a PMB level of care. 'The only exception is the diagnosis of COVID-19 in patients who are admitted with suspected SARS-CoV2 infection and test negative for RT-PCR, including children with suspected multisystem inflammatory syndrome,' says Dr Kabane.

To compare medical aid quotes and find the right one for your needs, head over to the Hippo.co.za medical aid comparison tool and get the low-down on comprehensive medical aid and hospital plans.

This article is for informational purposes only and should not be construed as financial, legal or medical advice.