Medical Aid and why you need it

For South Africans without medical aid, things can get exuberantly expensive very quickly, paying for medical treatments yourself can be financially crippling or Alternative, 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 member’s age and how many years for which they were not covered. Penalties range from 5% to 75% of the total member contribution.

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. 

What is a Waiting Period? 

The waiting period can be categorized 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 can’t refuse to cover treatments during the waiting period if they are listed as a PMB treatment or condition.

Day-to-Day Limits 

Medical aids give members and any dependents they may have a maximum amount of funds for any out-of-hospital expenses throughout the year. This limit is known as a day-to-day limit. 

Once you reach the limit of this pre-determined amount, you move into what is called an Above Threshold Benefit.

Co-Payment 

 Sometimes medical aid schemes do not cover the full cost of treatment if the service provider charges more than medical aid rates. 

Medical aid rates refer to the amount that your scheme is prepared to pay for a particular treatment. Where there is a shortfall with what they are prepared to cover, you will be required to pay the balance. This is known as a co-payment.

Depending on which plan you are covered with, the scheme can pay anywhere from 100% of medical aid tariffs up to 300%.

Co-payments can vary depending on the scheme and which network hospital or service provider you use. 

Choosing the right medical aid option can be incredibly confusing, 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, its difficult to navigate and best to do through a broker.