The Covid-19 benefit covers the out-of-hospital management and appropriate supportive treatment of global WHO recognised disease outbreaks and out-of-hospital healthcare services related to COVID-19. This benefit offers funding for the Prescribed Minimum Benefits (PMB) as well as additional funding and does not affect a member’s day-to-day benefits, as long as it meets the Scheme’s clinical and benefit entry criteria. Hospitalisation for Covid-19 is funded from the hospital benefit.
For more information on the Corona-19 virus please visit our dedicated Corona-19 page.
I consult with a doctor because I think I have COVID-19 Will the Scheme pay for my consultation?
Yes, the consultation will be paid from your day-to-day benefits if your test result is negative. You have access to a telephonic, virtual or a consultation in person with your doctor
Will the Scheme pay for the consultation if my result is positive?
Yes, your consultation will be paid by the Scheme.
The doctor suspects that I might be COVID-19 positive
Will the Scheme pay for my test?
Yes; you need to be screened by your doctor and if confirmed that you present with COVID-19 symptoms, referred by your doctor for the test
Unless PMB, tests will be limited.
Will the Scheme pay for the test if my result is negative?
Yes, your test will be paid by the Scheme if you have undergone proper screening and referral (see below for more information)
BASKET OF CARE FOR COVID-19 POSITIVE MEMBERS
I tested positive for COVID-19
Will the Scheme fund my treatment and tests?
Yes. The Scheme will pay
- Consultations for the diagnosis and follow-up care
- Pathology tests for the diagnosis and follow-up
- X-rays and scans
- Supportive medication
- Consultations and tests in excess of this benefit will be considered on a case by case basis.
What do I need to do to get access to COVID-19 Benefits?
Phone the Call Centre on 0860 222 633 to register your condition, if you have not already been contacted. The Basket of Care will be made available for your treatment.
What if I need to be admitted to hospital for COVID-19?
The normal authorisation process will apply and your claims will be funded in full by the Scheme.
Other Benefits in addition to the Prescribed Minimum Benefits
- Pre-admission Covid-19 test: Should you need to be admitted for a non-COVID-19 diagnosis.
- Pulse Oximeters for high risk patients as per Scheme clinical criteria on the Managed and Standard Care Plan.
- Oxygen via an oxygen concentrator as per Scheme clinical criteria and Designated Service Provider Rules.
Scheme funding for Covid-19 testing
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.
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.
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.
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 the use of 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.
Please note that, due to the nature of Covid-19 and updates in regulation, benefits and protocols might change. Above information is subject to change without notice.