What to consider when switching your medical aid cover

We all have different health and medical aid scheme requirements; and while many of us have been with our medical aid provider for some time now, it may not be a bad idea to review our current plan. Alina Hardcastle gets advice from experts who suggest the following factors to remember when considering changing your medical aid scheme:

  1. Waiting periods and pre-existing conditions

According to the Medical Schemes Act, no medical scheme can deny any applicant medical scheme cover. They can only apply certain restrictions to your membership. Tracy Janssens, branch head at Alexander Forbes Health, highlights the following restrictions:

  • A three month general waiting period meaning that you pay contributions but receive no benefits for a period of three months.
  • A 12 month condition specific waiting period which means that you’re not covered for a specified pre-existing condition for a period of 12 months, but you will be covered for other medical expenses not related to your condition.
  • Late joiner penalties apply to applicants over the 35 years old who have not had previous medical cover. This penalty means that they will be paying more for same benefits as other members.

Remember that if you had previous cover and have less than a 90 day gap between your old and new scheme, your new medical aid is obliged to offer you cover for a basic set of treatments and chronic conditions known as prescribed minimum benefits (PMBs). This is a list of 27 chronic conditions, 270 diagnoses and treatments and all emergencies. This cover also applies during waiting periods.

However, Janssens explains that schemes only covers these prescribed minimum benefits at designated service providers (DSPs), meaning that they prescribe which doctor, hospital or pharmacy you may.  Therefore, it is important to check who the scheme uses as a DSP before accepting a three month general waiting period.

She also adds that a scheme may not place any restrictions on your membership if you are already on the medical scheme (with no restrictions) and just switch between options or plans within the medical scheme.

  1. Positive savings account balance 

If you switch from a medical aid option that has a savings account component with a positive savings balance, this money can either be paid out to you or transferred to a new medical aid savings account.

  1. Negative savings balance

Medical aids usually provide for savings to be paid into members’ accounts in advance, pro-rated to the start date of cover. Should a member utilise the full advanced savings and switch plans prior to the end of the benefit year, the overused savings will be refundable to the scheme.

  1. Pro-rated benefits

When is it suitable time to switch your medical aid scheme? Karin Claasen, marketing manager for Momentum Health, says that ideal time to switch your medical plan is 1 January and the worst time would be the closer you get to the end of the year. “Benefits are pro-rated so if you join later, you will get fewer benefits.”

  1. Notice period

It’s illegal to have separate schemes with two different medical aid providers at the same time. If you are intending on cancelling your existing medical aid cover, keep in mind that your medical aid requires at least one month’s notice.

In conclusion

It’s vital to weigh up your needs versus level of affordability. Claassen says that you need to anticipate what your medical needs will be in the coming year and fully understand the benefits and limits provided by the alternative option and/or scheme to ensure you’re covered adequately.

It’s advised that a full needs analysis is conducted with a financial advisor to help guide you through this process.

To compare different medical aid products from a range of South African providers, click here.