Are you thinking about changing medical schemes but not sure of the risks? Medshield shares guidance

But switching medical schemes isn't as simple as it sounds. Don't only focus on the lowest premium. Look at hospital cover, day-to-day benefits, and dental and optometry benefits. Ensure the healthcare providers you regularly visit are part of the scheme's network, or you could pay a lot more out-of-pocket. And if you aim to manage a healthy lifestyle, consider that some schemes offer extra perks like wellness programmes, and preventative screenings.

Pre-existing conditions, waiting periods and late-joiner penalties can make this process more complex than expected. Don't worry – you can smoothly transition with the correct information.

There could be a waiting period

When switching medical schemes, one of the first questions you'll ask is whether your new scheme will cover your pre-existing conditions. It is a significant consideration, particularly if you have chronic conditions like diabetes, high blood pressure, or asthma. Fortunately, regardless of your medical history, South African medical schemes are required by law to provide cover for 26 chronic conditions defined in the Chronic Disease List as part of the Prescribed Minimum Benefits (PMBs). These include conditions such as hypertension, epilepsy, and HIV. However, this doesn't mean all is smooth sailing.

When you switch to a new medical scheme, they may impose waiting periods:

Members who belonged to their previous scheme for more than two years:

The new scheme can impose a 3-month general waiting period. PMBs are fully covered during the waiting period.

Members who belonged to their previous Scheme for less than two years:

The new scheme can impose a 3-month general waiting period and a 12-month condition-specific waiting period. PMBs are fully covered during the waiting period.

You might face late-joiner penalties

Late-joiner penalties are one of the most misunderstood aspects of medical scheme. Medical aid schemes can apply late joiner penalties if you join after the age of 35 or if there were breaks in your medical aid coverage since turning 35.

This penalty can range from 5% to 75% of your total premium, depending on how long you were without cover from a medical scheme. The purpose of the late-joiner penalty is to encourage people to join medical schemes early rather than wait until they're older and more likely to claim. The longer you've gone without medical cover after the age of 35, the higher the penalty:

• 5% for 1–4 years without cover
  
• 25% for 5–14 years without cover
  
• 50% for 15–24 years without cover
  
• 75% for 25 years or more without cover

You can avoid this penalty by switching schemes and maintaining continuous cover from the age of 35.
Late joiner penalties do not apply to members or their dependants who were members of a medical scheme before 1 April 2001 and who have not had a break in coverage for more than three months consecutively.

You may need some gap cover

While medical schemes offer substantial cover, they don't cover everything. Medical specialists and hospitals can charge rates higher than your scheme's payout limit, leaving you with a hefty bill. That's where gap cover comes in. Gap cover is an insurance policy that helps bridge the shortfall between what your medical scheme pays and what you are charged.

If you are considering switching medical schemes, assessing whether you need gap cover is a good idea. Sometimes, your new medical scheme may offer more comprehensive in-hospital benefits, meaning you might not need gap cover. But in most instances, especially for significant surgeries or specialist treatments, gap cover is a valuable safety net for out-of-pocket healthcare costs. If you're switching to a scheme with limited cover for specialists or hospital care, having gap cover is highly recommended.

The timing will matter

Medshield Medical Scheme members are free to change between benefit options or plans within the same scheme once a year during November and December, and the change will be effected on 1 January 2025. Should you choose not to change your benefit option, you will automatically remain on your current option for 2024.

It is also the best time to switch if you want to move from your current medical scheme to Medshield. All your specific details and medical history will be recorded for ease of reference when you begin your new journey with us. We welcome all new members, individual or corporate and offer a wide range of benefit options tailored to specific needs. Visit our website for more.