Scheme funding for Covid-19 tests

Even though media is reporting on a reduction in positive cases and testing, you might still need a COVID-19 test for some time.

Requirement for funding: screening and referral by a doctor
You always need to be screened by a doctor and get a referral to a pathology laboratory for the test to be paid by the Scheme. Whether the result is negative or positive, the test will be paid by the Scheme and not from your normal day-to-day benefits. The benefit limit for negative tests is one test a year. If the test is positive, it will be funded as a Prescribed Minimum Benefit (PMB).

Self-referral to a pathology laboratory
If you self-refer (without a referral by your doctor) to a registered pathology laboratory like Ampath, Lancet, Pathcare, etc., the Scheme will not fund the test. The Medical Savings Account can be used on the Managed Care Plan if performed by a registered pathology laboratory. Members on the Standard Care Plan will have to pay for these tests from their own pocket.

Drive-through testing
This service might be offered by a registered pathology group or a pharmacy group. As above, if you have not been screened by a doctor and did not obtain referral to go to a pathology group with a practice number, the test will not be paid. The Scheme can only pay claims, as per Scheme Rules, if the service provider can bill with a valid tariff code.

Home testing
If your doctor refers you for a test and you opt for a nursing practice to perform a test at home, the test will be paid, as long as the test is performed by a registered pathology practice.

Pre-admission Testing
Before patients can be admitted for elective (planned) surgery, they need to be tested for COVID-19. You still need a referral from a doctor and to use a registered pathology laboratory for the test. The Scheme will cover one pre-admission test per year.

Before you go to a pathology laboratory, whether for a COVID-19 test or other pathology, call and ask if you can make an appointment instead of queueing with other patients.