Coronavirus and medical schemes – What are the implications?

“Coronavirus is yet to test the rules of medical schemes,” Michelle David, Director at Norton Rose Fulbright South Africa Inc recently stated in an article where she weighs in on the implications of the coronavirus and medical scheme benefits.

“While it has been reported that a virus like COVID-19 would not usually be covered as a prescribed minimum benefit condition, where the virus amounts to an emergency condition then it will fall within the PMB legislation. In addition, to the extent that the virus results in medical consequences such as cardiac injury, the resultant condition may fall within the PMB provisions,” she shares.

In a circular sent out to medical schemes last week, the Council for Medical Schemes (CMS) confirmed that the diagnosis and management of uncomplicated Covid-19 infection is not included in South Africa’s Prescribed Minimum Benefits. “COVID-19 infection may, however, result in various complications. Most of the complications are included in the PMBs and should be treated as specified for the specific condition,” the CMS’s circular states.

How did medical schemes respond?

In a notice sent to members last week, South Africa’s largest private medical scheme, Discovery, said that DHMS and all primary care cover policyholders will have access to full funding for testing and treatment costs for confirmed Covid-19 cases.

“It is notable to point out that benefit design, governance and rule changes typically take months to mature. In this case, we have been nimble and proactive to meet members’ potential needs,” Discovery Health CEO Ryan Noach shared in a Business Insider article.

Momentum Health’s Marketing head Damian McHugh said coronavirus coverage will depend on their members’ plan. “Someone can therefore for example not visit a doctor on a hospital plan, as hospital plans do not contain day-to-day benefits,” he clarified.

Bonitas Medical Fund’s principal officer Lee Callakoppen said while the scheme had received minimal queries on the coronavirus, its call centre team had been fully briefed and trained to respond to queries about the coronavirus. “We feel we are as prepared as we can be at this time but will continuously re-evaluate our plans as and when circumstances change,” Collakoppen said. “Everyone is on high alert and on standby to assist any member who might contract the coronavirus.”

“Every scheme holds reserves specifically for events like this. The problem is, if an outbreak is sustained for too long then those reserves will deplete quickly,” CEO of Profmed Medical Scheme Craig Comrie shared.

Comrie also warned that it is essential that a coordinated approach is supported between the private sector and government to assist any who are infected. Funding the treatment for a widespread pandemic will place significant financial burdens on individuals, medical schemes and the government.

“In addition to providing cover as set out in the rules of a scheme and the Medical Schemes Act, the board of a scheme must also take all reasonable steps to ensure that the interests of beneficiaries are protected. Given the highly contagious manner in which COVID-19 can spread, it may be argued that it is in the interests of beneficiaries to provide the care that is needed to infected persons to limit the spread, and that such cost of care must be provided on an ex gratia basis if not falling within the ambit of the rules or the PMB legislation,” Michelle David concludes.

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