FYI: medical aid waiting periods
Thinking of changing your medical aid? Here’s what you need to know about switching and the conditions that come with new memberships
THERE are waiting periods when switching from one medical aid to another before you’re fully covered. The duration depends on how long you’ve been a member of a medical aid.
Basically, there are two categories: having been a member of a medical aid for an uninterrupted two years; and having been
MORE THAN TWO YEARS UNINTERRUPTED
If you’ve been a member of a medical aid for two uninterrupted years and switch to a new medical aid within 90 days of leaving your old one, the waiting period is usually just three months.
During these three months you’ll have to pay your full monthly premiums but you’ll be allowed to claim only for prescribed medical benefits (PMBs) – benefits that medical aids are required by law to cover. PMBs include hospital cover for a range of conditions and life-threatening emergencies, and treatment for a list of chronic conditions.
The full list of PMBs is published on medicalschemes.com. Procedures and medication related to PMBs are fully covered provided you use the fund’s preferred service providers and medication.
When the three months are over, the full benefits of your chosen plan option come into effect.
The penalty for joining late is called a late joining fee and is applicable only if the member is older than 35, as older members usually have more medical expenses. It’s calculated according to your total a member of a medical aid for less than two years.
If you want to switch, it’s important to do it within three months (90 days) of leaving your old medical aid or a late joining fee and full underwriting might be implemented.
Full underwriting means the same criteria could apply as when you join a medical aid for the first time. number of membership years and your current age. The longer you were a member of a medical aid, the less the penalty. This fee forms part of your monthly premium.
Go to medicalschemes.com for an explanation of how the late joining fee is calculated. The new medical aid will tell you what the fee will be, or you can consult a medical broker (see Get Help Here).
Even if the new premium is for instance R50 higher as a result of the penalty, you shouldn’t be put off. Rather compare the new fund’s benefits to those offered by your previous medical aid. EXAMPLES OF CLAIMS DURING THE WAITING PERIOD
Sarah has been a member of a medical aid for five years but switched to a new one as its benefits better suit her budget and needs. She’s now within the threemonth waiting period.
Sarah has high cholesterol. Because this chronic condition is a PMB, the new medical aid will cover her doctor’s visits and medication, provided the doctor and the meds are on its list of preferred service providers and medication. If Sarah was in a serious accident and her condition was critical, she’d be covered because this con- stitutes a life-threatening emergency under PMB cover.
Sarah has a sinus infection and visits her GP. The medical aid doesn’t cover the doctor’s visit nor the prescribed medication as she’s still in the three-month waiting period and the condition isn’t a PMB.
A MEMBER FOR LESS THAN TWO YEARS UNINTERRUPTED
If you were a member of a medical aid for less than two years and join a new fund (within 90 days of leaving the old fund), the new medical aid might require a 12-month conditionspecific waiting period on any existing conditions (such as hypertension) and planned procedures (such as a back operation). During this period you pay the full monthly contribution but medical expenses relating to the existing condition are paid out of pocket.
The 12-month exclusions are unique to your specific health conditions.
The three-month waiting period doesn’t apply to other medical expenses and you’ll be allowed to claim according to the plan you’re on. You’re also covered for PMBs.
A late joining fee can be implemented if you’re older than 35. EXAMPLES OF CLAIMS DURING A WAITING PERIOD
Josh was a member of a medical aid for 18 months and has now switched to a different fund.
He has a sinus infection and visits his GP within the first three months of his membership with the new medical aid. The new fund pays his doctor’s visit because his chosen plan covers doctors’ visits and prescription medicine.
Josh had a back operation before applying for membership to the new medical aid, so the new scheme excludes any claims for 12 months that relate to his back condition. For 12 months he has to pay for medicine for his back out of his own pocket. Make sure your new membership starts on the day after your old membership ends – it’s illegal to belong to more than one medical aid at a time. Before switching, call your existing medical aid and ask what the notice period is. When giving notice, confirm exactly on which day the membership ends.
Your old medical aid should give you a membership certificate, which you have to hand over to the new medical aid to confirm you were a member. If you don’t have this, you can sign an affidavit to confirm your membership.
The new fund will require your detailed health status and that of your dependants. This includes chronic conditions, medical history and any surgeries you’ve had.
If you stay with the same medical aid but change plans, there’s no waiting period. So before you switch to a new medical aid, establish whether your current medical aid has a different plan that might suit you better.