Covid-19: How does medical aid pay for tests?

When does your medical aid have to pay for a Covid-19 test, and when is it left up to its own scheme rules? Avoid nasty surprises.
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Testing and treatment for Covid-19 is considered a “PMB level of care“, which means that your medical aid needs to pay for this “out of risk” (their funds) and not your medical savings account. The information below is the minimum cover required. Your scheme might have more comprehensive cover, but it cannot have lower cover. Remember, medical insurance is not the same as medical aid and does not come with PMB level of care requirements.

RT-PCR testing for COVID-19 is PMB level of care upon referral from a health care worker (doctor or nurse) who has screened a patient. Patients to be tested are individuals who meet the criteria for a person under investigation. The criteria for suspected case are listed here.

In addition to a RT- PCR, and where clinically indicated, the following laboratory investigations are also recommended as PMB level of care for confirmed cases depending on the severity of symptoms:

  • Full blood count including differential count
  • Nasopharyngeal swabs or aspirates and oropharyngeal swabs for detection of viral and atypical pathogens
  • Sputum for MCS and Mycobacterium tuberculosis detection (GeneXpert MTB/RIF Ultra)
  • Other adjunct investigations that may be clinically appropriate or indicated will require motivation e.g. liver function tests, renal function tests, CRP, glucose, D-dimer levels, prothrombin, blood gas, and urine for lipoarabinomannan (LAM) test if HIV positive.

The RT-PCR test should be funded from the risk benefit irrespective of the RT-PCR result.

A single positive RT-PCR test is sufficient proof of COVID-19 infection, and there is no role of repeat confirmatory test. A repeat confirmatory RT-PCR test is not PMB level of care.

An RT-PCR test can however be falsely negative due to factors such as sampling technique or timing of the test. If alternative diagnosis has been explored and there is still clinical suspicion of COVID-19, a motivation should be submitted to the scheme for a repeat test.

There is currently no evidence that people who have recovered from COVID-19 and have antibodies are protected from a second infection. As such CMS does not recommend capping the number of RT-PCR tests per member; if a member presents with COVID-19 symptoms, and meets the NICD case definition, a RT-PCR test is recommended.

As per NICD guidance, asymptomatic people should not be routinely tested. CMS therefore recommends discretionary funding for the testing of asymptomatic people. This includes asymptomatic people who are returning to work.

Imaging Radiology

Imaging modalities are not recommended as PMB level of care for screening or diagnosis of COVID – 19, as the definitive test for SARS-CoV-2 is the RT-PCR.

Chest X-ray is recommended as PMB level of care for patients with confirmed COVID-19.

CT scan is recommended as PMB level of care in patients presenting with features indicating worsening respiratory function. CT scan is also recommended in COVID-19 patients with functional impairment and/or hypoxemia after recovery from COVID-19.

View our other articles on Covid-19 and PMB Level of care or Covid-19 in general.

Source: This information is sourced directly from Council of Medical Schemes website, and their document titled PMB definition guideline: COVID-19 v5 and does not rely on our own independent research

Image: “coronavirus-covid-19” by Nursing Schools Near Me is licensed under CC BY 2.0

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