How to ... join a med­i­cal scheme

When you ap­ply to join a med­i­cal scheme, you may find that the scheme will en­force wait­ing pe­ri­ods or late-joiner penal­ties. You need to know your rights and the rea­sons the scheme will im­pose th­ese mea­sures. You should also be aware that it is bet­ter to

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The fi­nal steps in choos­ing a med­i­cal scheme are to work out what you will pay to be­long to your cho­sen med­i­cal scheme op­tion, whether you will pay any late-joiner penal­ties and whether the scheme will im­pose any wait­ing pe­ri­ods.

You may need to com­plete and sub­mit your ap­pli­ca­tion form be­fore the scheme will no­tify you for­mally of any wait­ing pe­ri­ods and late­joiner penal­ties it will ap­ply.

Be­fore it sends you such no­ti­fi­ca­tion, the scheme may re­quest fur­ther in­for­ma­tion from you about your mem­ber­ship his­tory, your med­i­cal con­di­tions or those of your de­pen­dants, and/or your in­come.

The med­i­cal scheme may in­sist on a med­i­cal re­port so that it knows whether to ap­ply cer­tain wait­ing pe­ri­ods, but the scheme must pay the costs of any med­i­cal tests or ex­am­i­na­tions it re­quires.

The let­ter you get back from the scheme, known as the counter-of­fer let­ter, will de­tail the terms and con­di­tions of your be­com­ing a mem­ber. Th­ese are valid for 30 days.

You should sign the ac­cep­tance form only af­ter you have read the terms and con­di­tions care­fully, and have en­sured that you un­der­stand and agree to them. Do not sign if you do not agree with any wait­ing pe­riod or late-joiner penalty the scheme im­poses.

Also, if you al­ready be­long to a scheme, do not can­cel your mem­ber­ship un­til you have re­ceived for­mal no­ti­fi­ca­tion that an­other scheme has ac­cepted you as a mem­ber.

To work out what you will pay to be­long to a scheme, check the rates the scheme charges for a mem­ber. If you have de­pen­dants, add the rates for each adult de­pen­dant and each child de­pen­dant.

Be­fore you work out the fi­nal amount, if you have not been a mem­ber of a scheme con­sis­tently since the age of 35, check whether the scheme will im­pose any late­joiner penal­ties, as th­ese could raise your con­tri­bu­tions sig­nif­i­cantly.

WHEN LATE-JOINER PENAL­TIES WILL AP­PLY

Med­i­cal schemes can ap­ply late­joiner penal­ties on peo­ple who join a scheme late in life when they are older and are more likely to need med­i­cal cover, or are al­ready in need of med­i­cal at­ten­tion.

The penal­ties are in­tended to en­cour­age peo­ple to join schemes while they are still rel­a­tively young and healthy to en­sure there is suf­fi­cient sub­sidi­s­a­tion by the young and healthy of the old and sick.

Open schemes have to ad­mit any­one who ap­plies to join, and the penal­ties help to pro­tect ex­ist­ing mem­bers from the neg­a­tive fi­nan­cial con­se­quences of the scheme ad­mit­ting older mem­bers who are likely to claim more.

If late-joiner penal­ties are ap­plied, you will pay a load­ing on your con­tri­bu­tions that will ap­ply for as long as you are a mem­ber.

If you change schemes af­ter be­long­ing to a scheme that im­posed such a penalty, the new scheme may im­pose the same penalty.

The late-joiner penal­ties can be ap­plied to any­one who joins a scheme, or to an adult de­pen­dant of that mem­ber, who is 35 years of age or older, who has had a break in mem­ber­ship or cover as a de­pen­dant on any scheme since March 31, 2001 and who does not have enough years of what is known as cred­itable med­i­cal scheme cover as a mem­ber and/or de­pen­dant.

If you think a scheme may im­pose a late-joiner penalty, con­tact it or get your bro­ker to in­quire what penalty will ap­ply. The penal­ties that may be ap­plied are laid down in reg­u­la­tions un­der the Med­i­cal Schemes Act.

The method a scheme will use to de­ter­mine the penalty is:

It will work out the num­ber of years you have been a med­i­cal scheme mem­ber. You can in­clude the num­ber of years you have been:

A mem­ber or a de­pen­dant of a med­i­cal scheme but not any years when you were un­der the age of 21 and a de­pen­dant of a med­i­cal scheme mem­ber;

A mem­ber or a de­pen­dant of an en­tity that does the busi­ness of a med­i­cal scheme that at the time was ex­empt from the pro­vi­sions of the Med­i­cal Schemes Act;

A uni­formed em­ployee of the South African Na­tional De­fence Force (SANDF), or a de­pen­dant of such an em­ployee, who got med­i­cal ben­e­fits from the SANDF; or

A mem­ber or a de­pen­dant of the Per­ma­nent Force Con­tin­u­a­tion Fund.

You can­not in­clude any pe­riod when you had health cover un­der an in­sur­ance pol­icy, nor any pe­ri­ods when you were out of the coun­try and cov­ered by a health plan or pol­icy in an­other coun­try.

If you join a scheme af­ter a break of more than 90 days from any pre­vi­ous mem­ber­ship or if you do not have two years of con­tin­u­ous mem­ber­ship when you join a new scheme, you will need to prove your pre­vi­ous pe­ri­ods of mem­ber­ship to the new scheme.

If you have lost the records of your pre­vi­ous mem­ber­ship of a scheme or if you were a mem­ber of a scheme that has been liq­ui­dated, you can sign a sworn af­fi­davit stat­ing when you were a mem­ber, and this can be used to negate all or a part of a late-joiner penalty.

Add the an­swer in step one to 35 (the age from which the late­joiner penal­ties ap­ply).

Sub­tract the an­swer in step two from your cur­rent age.

The an­swer in step three will de­ter­mine the penalty band and hence the max­i­mum penalty, as a per­cent­age of your con­tri­bu­tions, that will ap­ply ac­cord­ing to the fol­low­ing ta­ble: 1–4 years: con­tri­bu­tion x 0.05 5–14 years: con­tri­bu­tion x 0.25 15–24 years: con­tri­bu­tion x 0.50 25+ years: con­tri­bu­tion x 0.75 Schemes have the dis­cre­tion to waive late-joiner penal­ties, but some ap­ply them strictly re­gard­less of the rea­son for which mem­bers join a scheme late in life.

The late-joiner penal­ties ap­ply only to adult mem­bers and de­pen­dants and not to child de­pen­dants.

WAIT­ING PE­RI­ODS

Med­i­cal schemes are al­lowed to im­pose lim­ited wait­ing pe­ri­ods on you when you join a scheme, with harsher pe­ri­ods for those who join schemes without hav­ing be­longed to one pre­vi­ously, or af­ter a cer­tain break in mem­ber­ship. This is to pre­vent you from join­ing a med­i­cal scheme only when you are sick and need ben­e­fits.

Dur­ing wait­ing pe­ri­ods, you and/or your de­pen­dants will not en­joy cer­tain ben­e­fits. Schemes can im­pose:

A three-month gen­eral wait­ing pe­riod on all ben­e­fits. Dur­ing this pe­riod, you and your de­pen­dants are not en­ti­tled to claim any ben­e­fits, ex­cept some­times the pre­scribed min­i­mum ben­e­fits (PMBs).

A 12-month wait­ing pe­riod on ben­e­fits re­lated to a spe­cific con­di­tion. The con­di­tion-spe­cific wait­ing pe­riod can be ap­plied to any con­di­tion for which you or your de­pen­dants sought med­i­cal ad­vice, ob­tained a di­ag­no­sis, or for which care or treat­ment was rec­om­mended or re­ceived within the 12 months be­fore the date on which you ap­plied to join the scheme.

If a wait­ing pe­riod is im­posed and you change med­i­cal schemes be­fore that wait­ing pe­riod is up, your new scheme can im­pose whichever new wait­ing pe­ri­ods ap­ply, as well as the re­main­ing por­tion of the wait­ing pe­riod the pre­vi­ous scheme im­posed.

WHEN WAIT­ING PE­RI­ODS CAN­NOT BE IM­POSED

The Med­i­cal Schemes Act says schemes can­not im­pose wait­ing pe­ri­ods if:

You ap­ply for mem­ber­ship or reg­is­ter a de­pen­dant within 90 days of end­ing your pre­vi­ous med­i­cal scheme cover and the change is due to a change in your em­ploy­ment; or

If the change of med­i­cal scheme is due to your em­ployer chang­ing or ter­mi­nat­ing the group scheme for its em­ploy­ees, the ap­pli­ca­tion is made within 90 days of your em­ployer ter mi­nat­ing your cover with the pre­vi­ous scheme, the ap­pli­ca­tion is made within a rea­son­able pe­riod be­fore the start of a new year and your mem­ber­ship will start at the beginning of a year.

WHICH WAIT­ING PE­RI­ODS CAN BE IM­POSED WHEN

If nei­ther of the above con­di­tions ap­ply, a scheme may im­pose the fol­low­ing wait­ing pe­ri­ods:

A three-month gen­eral wait­ing pe­riod if you have been a ben­e­fi­ciary (a mem­ber or de­pen­dant of a mem­ber) of a scheme within the 90 days be­fore you ap­ply to join a new scheme and if you have been a ben­e­fi­ciary of one or more schemes for a con­tin­u­ous pe­riod of more than 24 months. The gen­eral wait­ing pe­riod will not ap­ply to the PMBs.

If you have not been a ben­e­fi­ciary of a med­i­cal scheme for a pe­riod of more than 90 days be­fore you ap­ply to join a new scheme, the scheme may im­pose:

A three-month gen­eral wait­ing pe­riod; and

A 12-month con­di­tion-spe­cific wait­ing pe­riod (if ap­pli­ca­ble).

Th­ese wait­ing pe­ri­ods will also ap­ply to any treat­ment that falls un­der the PMBs.

If you have been a ben­e­fi­ciary of a scheme within the 90 days pre­ced­ing an ap­pli­ca­tion to join a scheme but have not been a ben­e­fi­ciary of one or more schemes for a con­tin­u­ous pe­riod of 24 months, the scheme can im­pose:

A 12-month con­di­tion-spe­cific wait­ing pe­riod (but this will not ap­ply to the PMBs); and

The bal­ance of any un­ex­pired gen­eral or con­di­tion-spe­cific wait­ing pe­riod im­posed by the pre­vi­ous med­i­cal scheme.

The wait­ing pe­ri­ods are ap­plied to the mem­ber and each adult de­pen­dant in­di­vid­u­ally.

You can­not buy out of any wait­ing pe­riod, and you can­not re­main a mem­ber of one scheme and join an­other at the same time in or­der to have cover while the wait­ing pe­ri­ods on the new scheme ap­ply.

HOW LATE-JOINER PENAL­TIES ARE CAL­CU­LATED

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