With plans that have a savings facility, you get an annual allowance, known as your savings account. It is funded by a portion of your premiums over the year, although the full amount is available to you in January.

There is no financial advantage to a savings account, since all of the monies are paid by you. The scheme does not “top up” the account. In addition, a scheme can limit what you spend the money on, how much you spend per benefit and at what scheme rate claims will be paid from the savings account.

The main advantage of having a savings account is that the full year allowance is available for you to spend in January. It also forces you to be disciplined in saving for your day-to-day expenses.

Extra Funds/Allowances

Some plans have a day-to-day fund that is not directly funded by a portion of your premium. Different schemes refer to this by different names (allowance, extra funds, day-to-day fund, extended benefits etc).

This extra fund can be in addition to a savings fund, or can exist on its own.

If a plan has a savings fund and an “extra fund”, often day-to-day claims are paid from savings first, and when depleted the extra-fund will kick in.

Schemes enforce various rules and sub-limits on how this extra fund can be used and what it pays for. See each plan, and individual benefit for sub-limits.

Self payment gaps, threshold and above threshold

Some plans (the comprehensive ones) have a savings account followed by a self payment gap until a pre-determined threshold is reached. Once the threshold is reached, the scheme will start paying for day-to-day claims again.

For example, if a plan has a savings account of R10,000 and a threshold of R15,000 that means that the first R10,000 of your day-to-day expenses will be funded from savings account, after which you will pay R5,000 out of pocket for your day-to-day expenses. Once you have reached the threshold (ie once you have contributed the R5,000 out of pocket and reached a total of R15,000 for your day-to-day expenses), you have reached the plan’s threshold. All further day-to-day expenses are paid by the scheme, up to the Above Threshold Limit (ATB).

Some plans have unlimited above threshold limits, which essentially means that once you have paid the self payment gap, the scheme will cover all day-to-day expenses until the end of the year, subject to scheme rules.

Be careful though, as often a scheme will not add a full medical bill when working out if the threshold has indeed been reached. This can get pretty complex and frustrating, and is a cause of much confusion. In brief, this is how it works:

• In January, you get a bill from your doctor for R500
• The scheme rate for the service is only R350, but the scheme pays the full R500 from your Savings.
• You continue to accumulate bills, and pay the full self payment gap by August. You expect the threshold benefit to kick in in September.
• Your scheme informs you that you need to pay more than your self payment gap, because it needs you to also pay the R150 difference for the January bill. When adding up the bills to get to the threshold amount, the scheme only adds up bills at up to 100% scheme rate, regardless of the actual bill amount.
• In addition, a scheme will usually cover all bills in the above threshold benefit at 100% scheme rate, thus still potentially leaving you with an excess that you have to pay out of pocket.

The post How day-to-day benefits work (savings, threshold, etc) appeared first on Medical Aid Bible.

What the Medical Aid Bible does and does not do

We list and compare all benefits for all open medical aid schemes. An “open” medical aid scheme is one that any person can join, regardless of their employer or other criteria. We do not list closed or “restricted” schemes.

We enable information to be quickly compared or filtered according to your needs.

At the heart of what we are trying to achieve is “add transparency”. We want to give you as much information as possible, wipe away the jargon and confusion, and allow you to make an informed choice based on all the information that is available.

We do not rate or recommend plans, since the strength of each plan is highly dependent on the needs of the individual member. There is no “Plan-for-all”. Please do not email or call us to ask for plan recommendations.

Where to start

• If you do not fully understand PMBs, Scheme rates, DSPs, and Networks, read this first
• If you are looking for a new scheme or plan, and are cost-conscious, start here
• If you are looking for a new scheme or plan, and are particularly interested in a specific benefit, start here
• If you want to find or change a plan within a specific scheme, start here
• If you want to compare any two plans, go here
• If you want to discuss a medical aid plan, use our forums
• If you want to find out about specific medical aid rules, use our search function in the sidebar, or start here
• If you want to get in touch with us, go here

Finding a plan based on price

1. Understand that there are different cost aspects to a medical aid. At the base is the premium, which is what you must pay every month. On top of that your further contribution will depend on whether you choose a hospital plan, a plan with savings or a comprehensive plan. You can find out more here.

2. If you have children on your plan, you should note that some plans only charge for 2, 3 or 4 children maximum. Some plans charge for all children. In addition, different plans have different criteria for the “cut-off” age of a child. We list those on each individual plan.

3. Note that some plans charge a different premium for the same benefits based on your income. The lower your income, the lower your premium. We refer to these as “income based plans” and identify them on the plan pages.

4. Note that some plans offer cheaper premiums for the same plan if you opt to use hospitals and service providers in the Network only.

5. Use the links below to find plans in your price range:
Under R1,200 per month
R1,200-R1,500 per month
R1,500-R1,750 per month
R1,750-R2,000 per month
R2,000-R2,250 per month
R2,250-R3,000 per month
R3,000-R3,500 per month
R3,500-R4,000 per month
R4,000-R5,000 per month
R5,000+

Finding a plan based on benefits

1. We have divided the benefits into sections, such as “In hospital benefits”, “Oncology” and “Maternity”. Follow the links below.

In hospital benefits
Out-of-hospital benefits
Dentistry benefits
Optometry benefits
Oncology benefits
Maternity benefits
Medicine benefits
Mental Health benefits
Other benefits
Preventative benefits

2. You can also compare specific benefits within a single scheme. For example, if you want to find out which Discovery Health plan offers the best oncology benefit. You can do this by clicking on “View by Scheme” in the menu above, and clicking on the “All Benefits” link.

Finding or changing a plan within a scheme

1. Use links below to go to that scheme’s home page on this site. There you will find links to all the scheme’s plans, benefits and other important information.
Bestmed
Bonitas
Commed
Compcare
Discovery
Fedhealth
Genesis
Hosmed
Keyhealth
Makoti
Medihelp
Medimed
Medshield
Momentum
Resolution Health
Selfmed
Sizwe
Spectramed
Suremed
Topmed

.

The post How to use this site appeared first on Medical Aid Bible.

• any emergency medical condition;
• a limited set of 270 medical conditions (defined in the Diagnosis Treatment Pairs);
• and 25 chronic conditions (defined in the Chronic Disease List).

Schemes have to cover at least the prescribed PMB level of care for these conditions, without requiring co-payments or savings from you, even if the treatment is provided out-of-hospital. This applies to every plan.

Medical Aid Schemes obligations re PMBs

By law, the medical scheme have to cover the diagnosis, treatment and management of 270 pre-defined conditions, including most cancers. As a scheme member, you will not be required to make co-payments or use your savings for this treatment, even if it is done out-of-hospital.

Nevertheless, this is not free-for-all-ride.

There are important caveats of which you need to be aware.

DSPs

DSPs are Designated Service Providers. You will see this acronym often. DSPs are providers chosen by some schemes to provide the healthcare services for PMBs.

If you choose to use providers other than the DSPs, the scheme can require you to pay the difference between what your provider chargers and what the DSP would have charged.

It is perfectly legal for schemes to assign state facilities as DSPs, and many do. That means that, while you are a member of those plans, you will be required to (most likely) receive PMB treatment from a state facility, even though you are a member of a private medical aid scheme.

Throughout the year, we are going to add the DSP lists or criteria for each scheme. You can also use our forums to log your experience and read about other people’s experiences.

PMB protocol and PMB level of care

The government has identified and listed “treatment pairs” for all 270 PMB conditions, which outline the level of care a PMB patient needs to have funded by a scheme. For example,

You can see the full list here.

So what does “Medical management” mean? The government has defined it as follows:

“Where the treatment component of a category .. is stated in general terms (i.e.”medical management” or “surgical management”) it should be interpreted as referring to prevailing hospital-based medical or surgical diagnostic and treatment practice for the specified condition. Where significant differences exist between Public and Private sector practices, the interpretation of the Prescribed Minimum Benefits should follow the predominant Public Hospital practice,….”

In other words, the level of care that you need to receive is, in most instances, at minimum the level of care that you would receive if you were a patient of the state, in public facilities. However, in most cases you will receive these services from private facilities, unless your plan specifies “state facilities” only. Note that this is the minimum level of care, as required by law. Many schmes/plans offer superior healthcare coverage to the minimum that is required.

PMBs and cancer

Most cancers are considered PMBs, and therefore you are funded for out-of-hospital treatment for cancer under the PMB legislation, even if you are on a hospital-only plan.

However, there are some limitations. For starters, only treatable cancers are considered PMBs. Once again, according to the government notes:

In general, solid organ malignant tumours (excluding lymphomas) will be regarded as treatable where:
i) they involve only the organ of origin, and have not spread to adjacent organs
ii) there is no evidence of distant metastatic spread
iii) they have not, by means of compression, infarction, or other means, brought about irreversible and irreparable damage to the organ within which they originated (for example brain stem compression caused by a cerebral tumour) or another vital organ
iv) or, if points i. to iii. do not apply, there is a well demonstrated five year survival rate of greater than 10% for the given therapy for the condition concerned

If your scheme covers cancer as a PMB and your cancer does not meet the above criteria, it will not be covered.

Chemotherapy

In addition, there are specific criteria for tumor chemotherapy:

Tumour chemotherapy with or without bone marrow transplantation and other indications for bone marrow transplantation. These are included in the prescribed minimum benefits package only where Annexure A explicitly mentions such interventions. Management may include a first full course of chemotherapy (including, if indicated, induction, consolidation and myeloablative components). Where specified in terms of Annexure A, this may be followed by bone marrow transplantation/rescue, according to tumour type and prevailing practice. The following conditions would also apply to the bone marrow transplantation component of the prescribed minimum benefits:
i) the patient should be under 60 years of age
ii) allogeneic bone marrow transplantation should only be considered where there is an HLA matched family donor
iii) the patient should not have relapsed after a previous full course of chemotherapy
iv) (points i. and ii. shall also apply to bone marrow transplantation for non-malignant diseases)

(Note: “Annexure A” is this list“)

Organ transplants

The prescribed minimum benefits include solid organ transplants (liver, kidney and heart) only where these are provided by Public hospitals in accordance with Public sector protocols and subject to public sector waiting lists.

Diagnosis

Hospital treatment where the diagnosis is uncertain and/or admission for diagnostic purposes. Urgent admission may be required where a diagnosis has not yet been made. Certain categories of prescribed minimum benefits are described in terms of presenting symptoms, rather than diagnosis, and in these cases, inclusion within the prescribed minimum benefits may be assumed without a definitive diagnosis. In other cases, clinical evidence should be regarded as sufficient where this suggests the existence of a diagnosis that is included within the package.
Medical schemes may, however, require confirmatory evidence of this diagnosis within a reasonable period of time, and where they consistently encounter difficulties with particular providers or provider networks, such problems should be brought to the attention of the Council for Medical Schemes for resolution.

Also see:
List of the 270 PMB conditions (defined in the Diagnosis Treatment Pairs)

The post All about PMBs, and how schemes have to pay for them appeared first on Medical Aid Bible.

IMPORTANT: For an explanation of general treatments (example: “Medical Management”) please click here

NOS means “not otherwise specified”.

BRAIN AND NERVOUS SYSTEM

EYE

EAR, NOSE, MOUTH AND THROAT

RESPIRATORY

HEART AND VASCULATURE

GASTRO-INTESTINAL SYSTEM

LIVER, PANCREAS AND SPLEEN

MUSCULOSKELETAL SYSTEM; TRAUMA NOS

SKIN AND BREAST

ENDOCRINE, METABOLIC AND NUTRITIONAL

URINARY AND MALE GENITAL SYSTEM

FEMALE REPRODUCTIVE SYSTEM

PREGNANCY AND CHILDBIRTH

HAEMATOLOGICAL, INFECTIOUS AND MISC SYSTEMIC CONDITIONS

MENTAL ILLNESS

Chronic PMB conditions

Addison’s Disease
Asthma
Bipolar Mood Disorder
Bronchiectasis
Cardiac Failure
Cardiomyopathy
Chronic Renal Disease
Chronic Obstructive Pulmonary Disease
Coronary Artery Disease
Crohn’s Disease
Diabetes Insipidus
Diabetes Mellitus Types 1 & 2
Dysrhythmias
Epilepsy
Glaucoma
Haemophilia
Hyperlipidaemia
Hypertension
Hypothyroidism
Multiple Sclerosis
Parkinson’s Disease
Rheumatoid Arthritis
Schizophrenia
Systemic Lupus Erythematosus
Ulcerative Colitis

The post List of PMB conditions and their prescribed treatment appeared first on Medical Aid Bible.

Choosing the best medical aid for your needs is one of the most important decisions you need to take. The choice affects not only the level of your healthcare, but also has huge financial implications for you and your family.

Choosing the correct plan is a fine balance between your healthcare needs, your affordability and your risk aversion level. Since all three of these inputs are so personal to your individual situation, we cannot recommend a blanket “best” plan.

Although we have tried to simplify information as much a we can, we have not been able to avoid some of the necessary jargon, and we do not have full insight into how the schemes operate.

Forums

To add to the transparency, we have introduced Forums to the website, and we encourage you to participate. By offering you a forum for your own experience with a healthcare funding issue, and the specific scheme, we hope to add even more transparency to the healthcare system, as well as more accountability. We encourage you to participate and read the forums. You can find out more here.

Scheme Rate

This is the foundation block of how schemes pay for claims. Every healthcare “line item” has an IDC code, and each scheme sets the maximum price it will pay for that code. If your healthcare provider charges more than this scheme rate, you will have to pay the difference out of pocket.

There are two main exceptions to this:

• Some schemes pay at “200% scheme rate” or “300% scheme rate” on some plans. That means they those plans will pay a multiple of their basic scheme rate to the healthcare provider, thus minimising your out-of-pocket expenses.
• Some schemes guarantee that they will cover the healthcare cots of provider if the providers are part of the scheme’s network, or if the providers have a payment arrangement with the scheme. The actual rate the provider then charges is irrelevant to you

Lastly, if your plan offers an above threshold benefit, it is very likely that claims accumulate to the threshold at 100% scheme tariff only, regardless of the actual cost claimed.

PMBs

The medical aid sector is governed by the Medical Aid Schemes Act, and that Act directs medical aid schemes to pay for the diagnosis and treatment of 270 conditions according to certain guidelines, and without charging you the end user directly for the treatment.

In other words, when you get treated for any of the 270 conditions, the schemes have to cover your costs without asking you for a co-payment, and without using your medical aid savings.

These 270 conditions, known a Prescribed Minimum Benefits (PMBs) cause much problems and confusion, for schemes, healthcare providers and for you.

We are committed to using this website to offer as much transparency to PMBs as possible, while also pointing out their pitfalls. You can find a list of the PMBs here, a collection of all our PMB content here,and more general info on PMBs here.

Update: The government has indicated that it will re-look at the PMB legislation, and will implement changes as soon as March 2017.

Here is what you need to know now, applicable for now:

• The 270 conditions cover all life threatening conditions, as well as most cancers and other degenerative conditions.
• As a medical aid member, you are guaranteed in hospital and out of hospital treatment for these conditions.
• Only “treatable” cancers are considered PMBs. Read more here.
• Schemes can prescribe where you receive treatment for PMBs, and most have Designated Service Providers (DSPs) to offer this service. If you choose to not use a DSP for a PMB, you might be liable for extra costs, as schemes are not obligated to covers costs above those charged by the DSP. This is a very important caveat, since a lot of schemes/plan designate state hospitals as DSPs. Therefore, you might think you have coverage for private hospitals, but in fact if you are treated for a PMB you might be relegated to a state hospital, or have to co-pay for a private hospital treatment. You can read more about DSPs here.
• The Act pairs each PMB with the minimum treatment that must be covered by the scheme. Unfortunately, in most cases, this treatment is simply described under a blanket description of “Managed care”. In very simple terms, what this mostly means is that the scheme has to pay for the treatment that a public hospital would offer to a non-scheme member who suffered from the same condition.
  It is reasonable to assume that as a scheme paying member, you might want better, more advanced treatment. Be aware that this might cost you out-of-pocket. For more specific information on this, read about the obligations medical aid schemes have re PMBs.
• The good news is that you have to be offered treatment, including out-of-hospital treatment, for all PMB conditions, no matter what plan you are on. That means that if you are financially constrained, you can rest easy knowing that even the cheapest plans guarantee coverage and out-of-hospital treatment for many conditions that would otherwise be affordable to you.
• The bad news is that PMB coverage requires careful ongoing management from you the scheme member. You have to be very vigilant that you are getting the coverage that is due to you, that you are not co-paying, and that you are using the DSPs. There is more information on this on our website under each scheme, and you can also read all our PMB content here.

Types of plans

Hospital plans: these cover in-hospital costs only, as well as out-of-hospital costs for any approved PMB conditions (see above). Some schemes may offer some extra benefits like preventative care, standard dentistry etc.

Savings: some plans set aside a portion of your premium toward out-of-hospital or day-to-day costs. You usually get the full years value of the extra premiums available in January. Savings cannot be used by scheme to fund PMB benefits prescribed by law.

“Extended Funds”: Different schemes have different names for these, but essentially it is a “budget” that schemes allocate to you for day-to-day expenses.

Comprehensive plans: These plans usually offer a savings account (see above), and once that is depleted might force you to pay for out-of-hospital expenses out of pocket (self payment gap). However, after a while, when all the day-to-day claims that have been paid (either by scheme or by you) accumulate to a certain amount, the scheme starts paying all further claims once again. This is called “above threshold benefit”. Some plans limit this benefit, and some plans have it as unlimited, with sub-limits for various benefits. See more here.

Income based plans: Some plans are income based plans, which means that the premiums you pay as a member are adjusted on a sliding scale according to your income. The less you make, the less you pay. Schemes define “income” according to own rules, so check with the scheme.

Managed care

All schemes have managed care programs, which you need to join if you want to get the full benefits available for certain conditions. By joining such a program, you will most likely be assigned a case manager to help you manage your condition, get you the care that you need and ease the claim process.

The post How medical aids work appeared first on Medical Aid Bible.

A late joiner penalty is a permanent penalty, added as a percentage of the base premium (not the savings portion). It is meant to dissuade or penalise people from not belonging to a medical aid in their youth, when they are presumably healthy, and joining only when they get older, and are a bigger drain on the schemes.

Therefore, members who apply for medical aid coverage and are over 35 years old may have to pay a Late Joiner Penalty.

How is it calculated?

It’s a three step process:

• First we count out how many years it has been since you turned 35. (If you are under 35, the penalty band will not apply to you) (A)
• Then we work out how many years you have spent on a medical aid since you turned 21. (B)
• We then work out (A) -(B) to calculate your penalty band.

Penalty Band = (Current Age – 35) – (Years of credible medical aid coverage)

You then apply the Penalty Band to the table below:

Examples:

• You are 43 years old, and were a member of a medical aid for 5 years, (22-27 yrs old):
  Penalty Band = (43 – 35) – (5) = 3 years = 5% penalty
• You are 55 years old and were a member of two medical aid schemes in the past. One for 6 years (23-29 yrs) and one for 15 years (32-47yrs)
  Penalty Band= (55 – 35) – (6 + 15) = -1 = No penalty

Note:

• The late joiner penalty is calculated as a percentage of the basic premium (not the savings portion).
• Credible medical coverage is defined as belonging to a recognised medical aid scheme. If you cannot prove your past membership and have taken all reasonable steps to try and obtain proof, you can submit an affidavit outlining your past membership, and this has to be accepted by the scheme.
• According to the Medical Act, if a penalty has been applied incorrectly in the past, it cannot be claimed back. However, we feel that if this was due to an error on the part of the scheme, you should discuss it with them, or the Medical Scheme Council.
• Membership of an overseas medical aid does not count when working out the “years of credible coverage”.
• Late joiner penalties follow members, even if they change schemes.
• Schemes are flexible on this, and each have their own discretion on how/whether they apply the late joiner fee. Speak to them and negotiate!

We have come across a number of schemes who misrepresent how a Late Joiner Penalty is calculated, in their favor. Our explanation is taken directly from the Medical Schemes Act. Please let us know if your scheme works out the late joiner penalty differently from our formula below.

The post Will I have to pay a Late Joiner Penalty? appeared first on Medical Aid Bible.

Some schemes will have an appointed person who deals with escalated queries or complaints. If your complaint is not resolved to your satisfaction, ask your scheme if the matter can be escalated.

You can also contact the Council of Medical Schemes. This is “a statutory body established by the Medical Schemes Act to provide regulatory supervision of private health financing through medical schemes”.

The Council regulates all schemes, and you can submit a complaint to them at any time. Put all your communication in writing, and ensure that you submit all relevant information, including copies of all correspondence between you and your scheme. You can send this by registered post, or you can email it to [email protected].

You can also visit the Council of Medical Scheme’s website, or call them on 0861 123 267.

We also encourage you to voice your experience with your scheme on our Forums, including their response as well as the response from Council, if any. Please read our forum guidelines first, to ensure we maintain a useful, fair and dignified presence.

The post How do I complain about a medical aid issue? appeared first on Medical Aid Bible.

Determining when you can change your medical plan depends on whether you want to stay with the same scheme or not.

Staying with the same scheme

If you want to change plans, but not schemes, you can always do that at the end of the year, to start from January of the following year. Confirm deadlines with your scheme, or subscribe to our newsletter (below) and we will remind you of any deadlines when the time comes.

Most schemes will allow you to downgrade your plan at any time.

Some schemes might allow you to upgrade your plan at any time. Speak to them directly.

Some schemes will allow you to upgrade your plan to a higher plan in the middle of the year if you have been diagnosed with a condition that requires better coverage (for example, Bestmed will allow you to upgrade your plan if you have been diagnosed with cancer, and your current plan only allows treatment in State hospitals). Some schemes will place a time limit on this upgrade (for example, you need to change plans within 30 days of a new diagnosis).

Changing schemes

If you want to change schemes, you can do so at any time.

You cannot be a member of two medical schemes, so you need to time your change carefully: you need to resign from one scheme the day you become a member of the new scheme.

Note your schemes notice period. Most schemes have a 30 day notice period, but Fedhealth, for example, has a three month notice requirement.

What else should I know?

If your current plan has a savings fund, and you change plans in the middle of the year, your scheme will calculate how much savings you were entitled to on a pro-rata basis. If you have used less than this, they will refund you. If you have used more, you will need to pay it back.

If you change plans in the middle of the year to one that has limits on benefits, know that those limits will be worked out on a pro rata basis for the year. For example, if you join mid-year, and a benefit usually has a annual limit of R5,000, only half of that will be available to you for the remainder of the year.

When changing plans, be aware of waiting periods.

Also read How do I change my plan?

The post When can I change my medical aid plan? appeared first on Medical Aid Bible.

The Medical Act allows waiting periods to be imposed so as to prevent potential members from joining a scheme as they become ill. The idea is that members should join a scheme while they are generally healthy. It is, however, freely admitted by the department of Health and the Council of Medical Schemes that the legislation governing waiting periods was poorly drafted, and can result in medical schemes exploiting members who are “not necessarily engaging in opportunistic behaviour“.

There are two types of waiting periods: 3 month general waiting period and 12-month conditional waiting period.

3 month general waiting period

This is a waiting period that can be applied to all health services for the first 3 months of membership, including in some cases PMBs ie life-threatening conditions. For example, if you are involved in a car accident during this waiting period, it is very possible that you will not receive any coverage from your scheme for any claims.

12 month specific condition exclusion

According to the Act, schemes can restrict treatment for certain conditions for which “medical advice, diagnosis, care or treatment was recommended or received within the 12-month period ending on the date on which an application was made“. Even if some schemes ask for a medical history that extends beyond the past 12 months, they are not allowed to impose restrictions based on any medical history older than 12 months.

Which of the two exclusion, if any, can apply to you depends on your specific circumstance.

1.
You want to change plans within the same scheme.
Exclusions: None can be applied, although any current exclusions will continue.

or
2.
You have not been a member of a scheme for more than 90 days
Exclusions: Both the 3 month general exclusion (including PMBs) and the 12 month condition-specific exclusion (including PMBs) can be applied.

or
3.
You are changing schemes voluntarily, and have been a member of a scheme(s) for less than 24 continuous months.
Exclusions: The 12 month condition-specific exclusion (excluding PMBs) can be applied. No general 3 month exclusion can be applied.

4.
You are changing schemes voluntarily, and have been a member of a scheme for the past 24 continuous months or longer
Exclusion: Only the 3 month general waiting period (excluding PMBs) can be applied.

1. You are changing schemes involuntarily due to change in employment
   Exclusions: Generally, no exclusions can be applied.

Waiting periods and PMBs

Waiting periods that exclude PMBs mean that you must be treated for all PMBs during the waiting period (for example: injuries due to car accident).

Waiting periods that include PMBs mean that you will not receive treatment for PMBs, even life threatening ones (car accident). Some schemes might cover you for some PMBs, at their discretion.

Note that during the waiting period, the schemes are obliged to only offer coverage for PMBs according to the PMB level of care ie. through designated providers, including state hospitals only.

You can find out more about PMBs here.

It’s all at the discretion of the scheme

Schemes cannot impose more exclusions than allowed by law, but they can impose less. Speak to your potential new scheme to get clarification regarding waiting periods in your specific case.

You might also be interested in Late Joiner Penalties or “Waiting periods and pregnancy“.

The part of the ACT that deals with waiting periods:

The post What are “Waiting periods”? appeared first on Medical Aid Bible.

A medical scheme is generally not allowed to refuse you membership, including on the grounds of past-ill health, or you being a high risk.

A scheme, can, however impose waiting periods.

A scheme is also not allowed to charge you a different (higher) premium because of your past medical history. It can, however, impose a “late joiner penalty”, which can range from an extra 5% to extra 75% of the premium, depending on your age and how long you have not had medical aid coverage.

The post Can I be refused membership of a Medical Aid Scheme? appeared first on Medical Aid Bible.