Are You Covered for the COVID-19 Vaccine?

South Africa’s Council for Medical Schemes (CMS) has added the COVID-19 vaccine to its list of Prescribed Minimum Benefits in a move that comes as welcome relief to members of medical schemes. But a closer look at the regulations around COVID-19 vaccines and testing highlights the importance of knowing exactly what you’re covered for.

The updated PMBs, approved by Minister of Health Dr Zweli Mkhize, include any emergency medical condition, together with 25 chronic conditions and a limited set of 271 medical conditions. These now include screening, testing and medical management for COVID-19, including ventilation and rehabilitation (all classified under the PMB code 177D). PMBs must be paid for by every medical scheme for every member, regardless of their plan, monthly payments or number of claims, subject to the clinical protocols of the plan option.

“According to the Department of Health’s COVID-19 Vaccine Rollout Strategy, the vaccine will be made available to all South Africans in three phases, starting with frontline healthcare workers, followed by other essential workers and high-risk groups before the rollout is extended to the broader population,” says Bradley Du Chenne, CEO of online comparison platform Hippo.co.za.

“By law, and specifically in terms of the Prescribed Minimum Benefits, members of medical aid schemes must be provided with cover for the jab. Many of South Africa’s top medical aid providers are trusted Hippo partners, and we’re delighted to see them working together to generously help fund vaccinations for South Africans who aren’t their customers.”

Some medical aid providers have pledged that for every scheme member who gets vaccinated, another person without medical aid will also be provided with a shot. Under this programme, a total of about 14.4-million South Africans (including both medical aid members and non-members) will be vaccinated against COVID-19.  

But medical aid cover (including hospital plans) can be expensive, and it’s often limited to South Africans who are employed, and whose employers make significant contributions to their monthly payments. Medical insurance is cheaper than medical aid, but that’s partly because insurance (which falls under the Short-term Insurance Act and not the Medical Schemes Act) is not legally required to include PMBs.

“This leaves consumers with a lot to think about,” says Du Chenne. “With medical aid schemes helping to cover vaccines for non-members, what effect will this have on your medical aid premiums? Will you, as the member, end up swallowing those costs? And if you’re on medical insurance, will your provider cover you for the COVID-19 vaccine? The only way to know you’re still getting the best deal is to compare what’s available, and then make a decision based on your circumstances. You may want to change your provider, or ask your existing provider for a better deal.”

Members of medical aid schemes should also be aware that PMBs provided by doctors who are not Designated Service Providers are only covered in an emergency. It’s always best to check the clinical protocols of your plan when being admitted to hospital. “While you should be covered for the coronavirus vaccine if you’re on medical aid, you shouldn’t assume that you’ll be covered for a routine COVID-19 test,” says Du Chenne. “Also, if you are admitted to hospital for an elective procedure, you may have to undergo a COVID-19 test as part of that admission. This test would not qualify as a PMB, so your medical aid would not have to cover it and you would either have to pay for it yourself, or the payment would come out of your medical savings.”

Engaging with your current medical aid or medical insurance provider is absolutely vital during this pandemic, Du Chenne warns. Medical aid members should always confirm that cover will be provided before they undergo any medical treatment, while people with medical insurance should ask their insurer what their options are regarding the coronavirus vaccine. These might vary from case to case.

South Africa has seen a dramatic increase in COVID-19 cases this summer, with growing fears that this second wave of infections will be followed by a third wave in the winter. Official figures put South Africa’s identified positive COVID-19 cases at 1,4 million at the end of January 2021, with about 42 000 deaths. More than 8 million tests have been conducted across South Africa since the outbreak of the pandemic in March 2020.

“COVID-19 is putting significant stress on South Africans’ health and wellness, and on their household budgets,” Du Chenne concludes. “It’s never been more important for consumers to know exactly what they’re paying for, and to know that they’re getting the best value for their hard-earned money.”