Covid-19: Society update

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With world-wide data showing that older people are generally more vulnerable to Covid-19, the Society has been concerned that our membership may be especially hard-hit. So far, however, we have not seen any alarming statistics from our Society data, with only 279 beneficiaries having been tested to date. Of these tests, only 40 have been positive.

We have recorded two Covid-19-positive deaths (one in the Western Cape and one in Gauteng) as at 16 July 2020, and express our condolences to the families of these members.

We thank our members for having embraced the concept of social distancing to “flatten the curve”, and encourage you to continue with social distancing and rigorous hand-washing, and to wear a mask whenever you go out in public.

The Society continues to be here for its members, and wish you health and safety during these challenging times.

Covid-19 now a PMB condition

During the Covid-19 pandemic, it is important for medical schemes to provide the necessary healthcare benefits to members. In line with this, the Council for Medical Schemes (CMS) has declared Covid-19 as a Prescribed Minimum Benefit (PMB) condition and, as such, all published regulations and guidelines relating to PMBs will now apply to Covid-19 cases.

As per the CMS’s guidelines, the Society will fund consultations and pathology tests as a PMB (100% of cost) according to the Society’s PMB guidelines. This includes limiting the number of tests to two per beneficiary per year.

If the PMB criteria and/or guidelines are not met, consultations and pathology tests will be paid from the relevant Society benefits according to the rules and benefit availability.

In order for members to enjoy the PMB cover, it is important to notify the Society of the test once it is performed and the results are obtained by the member or beneficiary.

Testing: various scenarios

At this point, Covid-19 tests are covered as follows:

  • If you test POSITIVE for Covid-19, the cost of the test will be covered in full by the Society. This will apply irrespective of why the test was done. The test will be claimed under ICD 10 code U07.1 Person under Investigation (PUI).
  • If you are screened by a healthcare worker and referred for testing by that healthcare worker and the diagnosis is NEGATIVE, the related tests will also be covered in full by the Society. In this case you would be regarded as a Person Under Investigation (PUI) and the test will also be claimed under ICD 10 code U07.2 (PUI).
  • Hospitals are increasingly insisting on any patients, including those admitted for non-Covid-19 issues, to be tested for Covid-19 before admission. If you therefore need to be admitted to a healthcare facility for a condition or procedure not related to Covid-19 and are required to be tested for Covid-19 beforehand, you will not qualify as a PUI. In such a case, if the diagnosis is NEGATIVE, the ICD 10 code will be Z11.5 (screening code) the member will carry the normal 10% co-payment.