As the world continues its battle against the Coronavirus pandemic, the rollout of the vaccine has emerged as the new talking point across the globe. For South Africa, a country defined by acute dichotomies in resources and access; the question of how the vaccine rollout will impact on citizens is a critical public interest issue. The question of financing the acquisition and the rollout of the vaccine, requires the collaboration of multiple role-players across society. For a government burdened with competing demands on limited resources; getting the buy-in of the private sector is an important milestone. The country’s parallel social systems – where some members of the population have access to medical aid and private healthcare; and others have no healthcare coverage, puts the healthcare question at the epicenter of the socioeconomic dilemma.

The nature of the negotiations and complexities around the rollout of the vaccine, has led to countries sending only government-approved structures to the negotiation table. This means that the South African negotiation is a national mission rather than one made up of private and public sector parties negotiating independently and by consequence, competing with each other.

The unresolved dilemma relates to the issue of funding. However fruitful or laborious the negotiations around vaccine access eventually turn out to be; the unavoidable reality is that it will require financial resources. And the risk associated with government being the only primary negotiator, is simply that the cost of acquiring vaccines may be beyond the current financial capacity of the state. To this end, leveraging private sector participation is core to the national strategy. On the back of this, it was quite important that on Tuesday 5 January 2021, the Council for Medical Schemes (CMS) issued Press Release 1 of 2021 advising that the health minister Dr. Zweli Mkhize has approved COVID-19 vaccine to be included in the amended Prescribed Minimum Benefits (PMB) regulations.

What are Prescribed Minimum Benefits (PMB)?

In terms of the Medical Schemes Act No 131 of 1998, PMB’s are a set of benefits that all medical schemes need to cover on all the plans offered to their members. This cover includes the funding of the diagnosis, treatment and ongoing care for listed conditions. The full list of 270 diagnostic treatment pairs can be found on the Council of Medical Schemes website www.medicalschemes.co.za

The Council for Medical Schemes published a circular on 26 March 2020, declaring COVID-19 a Prescribed Minimum Benefit, the term COVID-19 is defined as “an acute respiratory illness caused by a novel coronavirus”. This simply means that all medical schemes are obliged to cover all costs associated with the treatment, screening and testing for members who contract COVID-19 and respiratory illness due to COVID-19.

In May 2020, the Council for Medical Schemes offered guidelines in alignment with the Medical Schemes Act No 131 of 1998. The guidelines were to ensure that members are covered in accordance with Prescribed Minimum Benefits regulations.

The importance of this development, is simply that if the state does acquire a vaccine on behalf of a citizen who is a member of a medical scheme, then the medical scheme itself is responsible for payment. The benefit of this amendment is two-fold. Firstly, by passing on the cost to the medical scheme, the amendment frees up the financial space for the state to only finance the vaccine for those citizens who are not covered by a medical scheme. Secondly, the various medical schemes offer varying levels of cover under different plans which often leaves members unsure whether all their conditions are covered. Such anxieties do not apply in relation to prescribed minimum benefits as all schemes are obliged to cover them. It is also important to note that members who may have amended their plans or downgraded at the end of last year in order to manage cash flows for example, are not going to be excluded even if their new plan is less comprehensive than their previous plan.

When you are referred by a medical practitioner for a COVID-19 test, the medical scheme will cover the cost of the test, irrespective of whether you test positive or negative. Further tests such as x-rays, CT scans and other medical investigations may also be required, and the medical scheme will cover these costs. However, in spite of these amendments, it is always advisable to contact your medical scheme to confirm benefits and scheme rules – particularly if you have recently joined or recently amended your plan. In some cases, members who join a medical scheme for the very first time or who have had more than 90 consecutive days since they were members of a scheme, may not be covered at all until the end of a ‘waiting period’. During this period, even the PMBs will not be covered.

An additional consideration is that you may be required to use a network of medical practitioners and hospitals, namely Designated Service Providers (DSPs) that are approved by your scheme. In times of curfews and lockdowns, knowing this information may prove to be invaluable.

As part of the commitment to solidarity during this pandemic, medical schemes have committed to contributing more than their share in the vaccine procurement programme. According to the CMS press release, a public-private collaborative approach has been adopted that will see medical schemes paying more for the vaccine and the medical scheme donating a percentage of the costs to a fund that would cover non-medical scheme members.

The vaccine roll-out is estimated to cost medical schemes R7.1 billion. Medical Schemes will follow the same priority order as the public sector for the distribution of vaccines. This means that health workers will be vaccinated first, followed by essential workers, worker in large institutions, the elderly (over 60 years) and those with co-morbidities. Healthy people below the age 60 will be last in line.

The Treasury has confirmed that it will pay for the majority of the population to receive COVID-19 vaccinations, when they become available. The government has set a target to vaccinate 40 million people by the end of 2021, with an average of 316 000 people receiving vaccinations per day at the height of the rollout. What remains important though, is the fact that non-pharmaceutical interventions like social distancing and masks; will remain an integral part of the fight against the virus; particularly given the period of time it will take for vaccines to be acquired and the inoculation process to reach significant scale.

It is advisable to contact your trustworthy medical aid broker to assist you whenever you need assistance with medical scheme queries or information.

Nonhlanhla Mzolo - Managing Director of Q and S Consulting (Pty) Ltd, an Insurance Brokerage specialising in Medical Aid and Short-term advisory services.