COVID19: What will my medical scheme pay for?

10 December 2020

Many South Africans breathed a sigh of relief when the country seemed to be over the peak of the first wave of the Covid-19 pandemic.  However, the alarming recent resurgence in cases is a stark reminder that we cannot afford to become complacent.

With the festive season around the corner, many of us will be attending family gatherings which could act as super-spreader events if we don’t stringently observe the now commonplace essential precautionary protocols like meticulous hand-washing, social distancing, wearing of masks and adequate ventilation.  Where possible, outdoor family gatherings and other activities are much safer than indoor meetings.

Even with best practices in place, it is inevitable that some of us will contract the virus and become ill. Given the healthcare costs associated with testing and treating, it is important for consumers to have peace of mind in knowing that the disease is covered by their medical scheme and to understand the benefits which they are entitled to.  

While these benefits may differ slightly, depending on the medical scheme plan you are on, there are certain benefits which are covered by all schemes, regardless of your plan.  

Lerato Mosiah, CEO of the Health Funders Association, an industry body for medical schemes and administrators, explains that the medical schemes industry and their regulator were quick to respond to the pandemic to protect their members from unnecessary out of pocket expenditure.  

“From as early as May, the Council for Medical Schemes (CMS) offered guidelines in alignment with the Medical Schemes Act.  These guidelines were updated to ensure that members are covered for screening, testing and treatment, in accordance with the Prescribed Minimum Benefit regulations.  Many schemes also offer cover above and beyond those as part of the scheme rules,” she says.  

Mosiah explains that certain COVID-19 benefits have been included in the list of Prescribed Minimum Benefits, which means that these are available to all members, regardless of the plan that they are on and that the costs associated with these treatments will be paid by the scheme and will not be deducted from a member’s medical scheme savings account.

“As long as you are referred for a COVID-19 test by a medical practitioner, your medical scheme will cover the cost of the test, regardless of whether you test positive or not. This includes cases where you may merely have been exposed to the virus and after screening, be referred by your healthcare professional for testing.  The cost of both screening and testing in such cases will be covered by your medical scheme,” she explains.

Depending on how severe your symptoms are, further tests, such as a chest X-ray, a CT scan or other investigations may be necessary. Where this is the case, these tests will also be covered by your scheme regardless of which plan you are on, provided that the medical practitioner has made the necessary referrals.  

Mosiah says that in many mild-to-moderate cases, home-based care will be sufficient to manage the symptoms. She adds that here too patients can rest assured that the necessary medications will be covered by the scheme, according to the scheme rules.  These include antibiotics for secondary infections and treatments for chronic co-morbidities such as asthma, HIV or diabetes.

“It is important to make contact with your medical scheme as soon as you can to ensure you benefit from the support that medical schemes have put in place to help you get the care you need,” she adds.

“Where a patient is at a higher risk of developing complications associated with hypoxia (low blood oxygen saturation levels) some schemes may also fund a pulse oximeter, which is a device for measuring the oxygen in your blood,” says Mosiah.

As with other PMB conditions, if you need to be admitted to hospital for treatment, these costs will be covered in full by your scheme. It is important to remember that if your medical scheme plan includes a network of hospitals or doctors, that you make use of these to avoid the possibility of having to pay out of pocket.

Once an effective vaccine is available, it is likely that this too will be covered by your scheme (as per your scheme rules) once it has been approved and included onto the National Essential Medicine List.  

“As we enter the festive season and the COVID risks which that brings, we must realise that the COVID-19 virus is part of our reality now, and will remain a prominent feature of the healthcare landscape for the foreseeable future, perhaps indefinitely,” says Mosiah.

“It is therefore important for medical schemes to continue to protect their members by providing for appropriate cover and for members to be assured that they have the necessary cover should they contract the virus.”  



Issued by HWB Communications Pty Ltd on behalf of the Health Funders Association.

About HFA:

HFA is a representative organisation for medical schemes, administrators and managed care organisations. It represents more than two thirds of all medical scheme principal members in South Africa. For more information, visit

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