Medical schemes have new rules, and prescriptions too – here’s what you need to know
New regulations have been gazetted for medical schemes, which compel them to pay for certain Covid-19 medical costs.
But this only applies in circumstances where a person is considered to be 'high-risk'.
Other new regulations mean you can temporarily get an automatic repeat on your medicine prescription without consulting a doctor.
In the past week, government has adopted new coronavirus-related regulations that brings changes to medical schemes – and, for some medicines, you temporarily can get an automatic repeat without going to the doctor.
According to new regulations, prescriptions for Schedule 2, 3 and 4 medicines are now valid for another six months.
This means that if you ran out of medicine during lockdown, you don’t have to get a new prescription from your doctor. This is in part to reduce the number of patients at doctors’ rooms, and curb the risk of infection. The pharmacist can extend the prescription for another six months.
However, the medicine may not be dispensed for a period longer than twelve months from the date of the issue of the initial prescription, says Neil Kirby, head of healthcare and life sciences at Werksmans Attorneys. This means that if you received the prescriptions six months ago, you can only get repeats from your pharmacy for another six months.
Schedule 2 medicines include treatments for coughs or flu symptoms, while Schedule 3 can include hypertension and diabetes medicines. Anti-retrovirals and antibiotics are Schedule 4 medicines. By law, Schedule 3 and 4 medicines can be repeated for six months – but this has now been automatically extended by another six months. The new regulation applies to November 2021, and excludes medicines from Schedule 5 and above (anti-depressants, sedatives etc.).
There are also new regulations for medical schemes, which include Covid-19 as a prescribed minimum benefit (PMB). PMBs are treatments for chronic conditions and other procedures that all medical schemes are compelled by law to cover in full, no matter what plan you are on.
There is still some uncertainty about which expenses must be covered, however.
“Our understanding of the amendment to the regulations, amending the prescribed minimum benefits so as to deal with Covid-19, is that the application of the prescribed minimum benefits only applies in circumstances where a person is considered to be 'high-risk' based on a set of criteria published by the Council for Medical Schemes,” says Kirby.
According to the CMS, high-risk patients are those who have an acute respiratory illness, and who have either been in close contact with someone with Covid-19, or had a positive travel history, or who worked in a healthcare facility with Covid-19 patients, or have been admitted with severe pneumonia of an unknown cause.
The treatments of those who fall into this category – including screening, tests, medication, hospitalisation, treatment of complications and rehabilitation – must be fully covered by the medical scheme.
“Where it may have previously been unclear whether or not medical schemes would cover the costs for the treatment of Covid-19 for members on lower plans, leaving the responsibility for payment on the State, the amendment, arguably, relieves certain financial pressure on the Department of Health in so far as the State is now obliged only to cover the costs of citizens who are not covered by medical schemes,” says Zamathiyane Mthiyane, senior associate in the health care and life sciences practice area at Werksmans.
The position is not clear in respect of asymptomatic people who choose to be tested for Covid-19.
Recent guidelines published by the CMS, state that asymptomatic patients "will be funded according to scheme rules", which appears to imply such testing will be funded from benefits available to the member other than prescribed minimum benefits, says Mthiyane.