As if deciphering all the medical aid jargon wasnâ€™t enough, choosing the right medical aid option can be incredibly confusing if you are not sure of the criteria you need compared to what is on offer.
Whether you are looking to revise your current medical aid benefits and terms, or you are new to the game and are looking for a medical aid to join, the information below contains all the information you need to know to make the right decision.
The main purpose of medical aids is to protect their members in the case where they need to pay a large amount for unexpected medical expenses. For South Africans without medical aid, things can get a little pricy.
You will need to pay for any medical treatments yourself which can be crippling. Alternatively, you could rely on state healthcare which may not offer the highest quality care.
Before you sign up for a medical aid plan, here are the main facts you need to know:
Penalty for Late Joiners
For individuals over the age of 35 that have not been a member of a medical aid before April 2001, a late joiner penalty is enforced by The Medical Schemes Act. This allows for the scheme to make provisions for older members that have not contributed to the risk pool before.
This penalty is not a once-off charge but rather gets added to the monthly contributions and will be deducted indefinitely without expiring. This penalty is calculated as a percentage based on the memberâ€™s age and how many years for which they were not covered. Penalties range from 5% to 75% of the total member contribution.
What is a Waiting Period?
By law, all medical aid schemes have to accept anyone who applies for cover. As a result, more sickly and older members can join later on in life when their risk is higher, even though they have not been contributing to the schemes risk pool.
This is why the medical aid scheme imposes waiting periods, to contest any risk of new members. Think of it as probation when you need to pay your contributions monthly, but you will not be able to claim any of the benefits until the end of the waiting period.
The waiting period can be categorised in two ways: a general waiting period usually of 3 months and a waiting period for pre-existing conditions which can last up to 12 months.
Waiting periods might apply if you have not been on another South African medical aid in the past three months or longer, or if you voluntarily opt to change schemes and have been a member with your current scheme for less than two years.
There is, however, an exception to waiting periods in the form of Prescribed Minimum Benefits (PMB). The scheme canâ€™t refuse to cover treatments during the waiting period if they are listed as a PMB treatment or condition.
This does not apply to members who have never been on a medical aid or have not had cover for 90 days prior to applying for membership.
What are PMBs?
PMBs consists of pre-determined treatments or benefits that South African medical aids have to cover regardless of your selected benefit.
Based on the Medical Aid Schemes Act, these benefits include diagnosis, care and treatment for emergency medical conditions that may be life-threatening, a list of 25 chronic conditions as well we a limited set of 270 medical conditions.
Use this information regarding late joining of medical aids, waiting periods and PMBs to make an informed decision about which medical aid scheme to choose. Should you wish to switch medical aids, be sure to pay attention to the timelines applied to waiting periods to ensure you are sufficiently covered.