COVID-19 treatment has been listed as a Prescribed Minimum Benefit (PMB) condition for medical scheme members by the Council for Medical Schemes (CMS). But what does this mean for you if you get 'long COVID', where you find yourself still experiencing symptoms months after you 'recover' from the initial period of sickness? Will your medical aid cover you?
Recovery from COVID-19 isn't always as straightforward as falling ill for a couple of weeks and then gaily bouncing back. As many as one in five recovered COVID-19 patients experience a variety of lingering symptoms – if they last for 12 weeks or longer, they are regarded as 'long COVID'.
The symptoms of long COVID range from an extended loss of taste or smell to fatigue, breathlessness, anxiety and depression, palpitations, chest pains, joint or muscle pain, and 'brain fog'.
The COVID-19-specific PMBs form part of the PMB Definition Guideline and include testing, diagnostics, treatment and rehabilitation – this just means that as a medical aid member, your COVID-19 journey back to health must be covered by your medical aid.
CMS registrar Dr Sipho Kabane says that since COVID-19 is an acute respiratory viral infection that may result in long-term complications, care – including rehabilitative and palliative care – of a COVID-19 patient is a PMB entitlement.
'Schemes are expected to cover costs of PMB conditions, including COVID-19 and medical emergencies, in full. These costs are subject to evidence-based and cost-effective clinical protocols, medicine formularies and designated service providers as published by medical schemes and administrators,' he says.
PMBs apply to all types of medical aid plans, including hospital plans. So the good news is yes, your medical aid and hospital plan should cover you for the length of your recovery and rehabilitation. But you'll still need to check the fine print properly to understand what exactly that entails. After all, there is a difference between medical aid and a hospital plan in terms of what will and won't get paid for by your insurer.
According to Alexia Graham, the director of Hippo Advisory Services, medical-aid schemes will apply clinical protocols, which can include designating which doctors or specialists you can use, and what drugs they'll pay for. 'It's important for members to ensure that they are aware of and adhere to the PMB protocols for their medical scheme as these will vary from one scheme and plan option to the next,' she says.
As to whether a medical aid offers a better level of care than a hospital plan, Graham says that while PMBs apply across both, it's important for members to understand the preferred provider and medicine formulary rules that apply to the plan that they're on. 'These protocols vary from one plan to the next,' she warns.
Graham explains the process using Discovery Health as an example. 'Discovery's KeyCare plan covers admission to a defined list of hospitals at which members can receive care. If they go to a hospital which isn't on that list, they can still access it, but may have to make a co-payment, which can have a major effect on the pocket, even if hospital admission for COVID-19 is a PMB. Medical schemes also impose clinical and medicine formularies for each plan, which affect members' access to facilities and types of treatment,' she says. 'For example, asthma is a PMB so a KeyCare member will be able to access prescribed treatment, but the list of medications they will be able to access [compared to] someone on a more comprehensive plan will be different. All treatment is subject to the rules the scheme imposes on the PMB bundle as part of the member's specific plan.'
A hospital plan generally covers scheme members for in-hospital treatments, with out-of-hospital treatments covered out of their own pockets. As with any other PMB, though, Graham says that COVID-19 rehabilitation is covered even post-recovery, 'that is, provided your treating doctor adheres to the clinical protocols required by your medical scheme,' she says.
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This article is for informational purposes only and should not be construed as financial, legal or medical advice.