to maximise your medical aid benefits
We live in a world of acronyms and industry jargon which can be very confusing. Decoding medical aid terms, will empower and help you to get the most out of your plan and benefits.
What and why is there a‘ waiting period’ when you join a medical aid scheme?
According to the Medical Schemes Act 131 of 1998, medical aid schemes are entitled to impose waiting periods on new members. So, if you have not previously been on a medical aid scheme or are moving from one scheme to another, there may be a waiting period.
There are two types of waiting periods: General waiting periods( up to three months) and condition-specific waiting periods( up to 12 months). This means you will continue to pay monthly premiums but are not covered during the period outlined by the scheme.
During a general waiting period, a beneficiary( member) is not entitled to any benefits, in some instances not even Prescribed Minimum Benefits( PMBs). Condition-specific waiting periods are related to a specific medical condition. During this time, a beneficiary is not entitled to any benefits for a particular condition for which medical advice, diagnosis, care or treatment was recommended or received.
A waiting period protects other members of the Fund by ensuring that individuals aren’ t able to make large claims shortly after joining and then cancelling their membership. Unlike other financial products, medical schemes are not-for-profit entities, they are highly regulated to ensure they fulfil a social solidarity role, i. e., everyone benefits from the dependence individuals have on each other.
What is a late-joiner penalty?
Medical aid schemes can impose late-joiner penalties on individuals who join after the age of 35, those who have never been medical aid members or those who have not belonged to a medical aid scheme for a specified period of time since April 2001.
If you are over 35 and haven’ t been on a medical aid, then – depending on your age – you will be penalised and pay a surcharge of between 25 % and 75 % of your premium. This is outlined by the Council for Medical Schemes( CMS) but is at the discretion of the scheme. This is to ensure fairness, whereby members who have been part of a scheme for years are not subsidising newer members who have not contributed to the scheme.
What are Prescribed Minimum Benefits( PMBs)?
PMBs are a list of defined benefits to ensure that all medical scheme members have access to certain minimum health services, regardless of the benefit option( plan) they are on. The aim is to provide members with continuous care, to improve their health and wellbeing and to make healthcare more affordable.
PMBs are a feature of the Medical Schemes Act, in terms of which medical schemes have to cover the costs related to the diagnosis, treatment and care of:
• Any emergency medical condition
• A limited set of 270 medical conditions( defined in the Diagnosis Treatment Pairs)
• 26 chronic conditions including diabetes, asthma and hypertension
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Bonitas Member Magazine Issue 3 / 2025