Operational Hours Mon - Fri: 8:00AM - 4:30PM
Information information@medicalschemes.co.za
+27 86 112 3267 +27 12 431 0500

Circular 56 of 2022: Extended exemption for late COVID-19 vaccine claims

The Council for Medical Schemes (CMS) wishes to appraise the industry that it has granted a further exemption to the National Department of Health (NDoH) to ensure that all COVID-19 vaccine claims are eventually paid despite these claims being submitted outside the ambit of Regulation 6 of the Medical Schemes Act (131 of 1998) (MSA).

The CMS believes that this decision is of public interest and in support of the overall management of the pandemic. Section 8(h) of the MSA gives CMS the powers to exempt medical schemes or other persons from complying with any provision of the Act, in exceptional circumstances.

The decision to grant exemption to the NDoH was based on various considered factors, such as the department’s lead in the COVID-19 vaccine roll-out for the entire population, based on a pre-determined criterion. The department carries the cost of vaccination for the section of the population that is not on medical schemes.

For medical scheme members, COVID-19 is a Prescribed Minimum Benefit (PMB), and screening, investigation, treatment, vaccination, and rehabilitation are covered in full.

The extended exemption was granted as a result of the backlog in the processing of COVID-19 vaccine claims. The delay is caused by queries relating to accounts which were rejected by medical schemes, but which were subsequently discovered to have been erroneously submitted to an incorrect medical scheme; claims from private providers for persons who have failed to declare their medical aid status were therefore identified by the providers as uninsured patients, but whom the NDoH subsequently identified as having medical scheme cover.

To that end, the NDoH envisages that the claims will not be finalised within the required time frames and as such, an extension will be necessary for the purposes of finalising the envisaged claims.

The department’s reimbursement is key for the sustainable provision of additional vaccines for the entire population, and the sheer volumes of claims and the resultant reconciliations that need to be done to ensure each claim is correctly identified and routed is a mammoth task and cannot be finalised within the required 120 days as prescribed by Regulation 6.

This exemption was and is critical to prevent the claims generated by the NDoH from being stale because of the strict time limits prescribed by Regulation 6(1) and (2).

Medical schemes are therefore authorised to process claims received on or before 365 days. Furthermore, the NDoH is allowed to submit claims after 120 days as required by Regulation 6(1) and (2) but must do so within 365 days.

The exemption will be valid for a period of three years or will expire once the NDoH has recovered all vaccine-related costs on all insured members of medical schemes.

This is in the interests of justice as the principal focus is to vaccinate the entire country. This allows the government to be reimbursed for vaccination for insured members of medical schemes.

Regulatory Framework References available on Medical Schemes Act (131 of 1998). 

  • Regulation6(1)(a)(b)
    •      Section 7
  • Section 8(h)(k)

The CMS looks forward to your co-operation.

Download the Circular here.