What Influences Medical Aid Schemes’ Quotes

What Influences Medical Aid Schemes’ Quotes

The Medical Schemes Act, 1998, which came into effect in 2000, stipulates that no person who applies to become a member of an open medical aid scheme, or their dependants, may be excluded on the basis of grounds such as age, gender, marital status, race, health status or medical history.

At the same time, medical schemes are not allowed to charge differing rates to members on the basis of these factors, in terms of the principle known as “community rating”. This means that all members of a particular medical aid “plan” or package have to be charged the same premium for membership, irrespective of factors such as pregnancy, HIV status or disability. Before 2000 medical aid contributions could be determined on the basis of one’s age, claims’ history, area where you lived, period of membership of the medical aid, etc, but since 2000 premiums may only be based on a member’s income and number of dependants. The law therefore guarantees that there will be no discrimination in the administration of medical cover in South Africa.

Late joiner penalty

However, one aspect in terms of which medical schemes are allowed to distinguish is in respect of those who have not joined a medical scheme timeously. If you join a South African medical aid for the first time only after the age of 35, you will incur a late joiner penalty. If you join between one and four years after age 35, you will have a 5% loading on your premium; between five and fourteen years after age 35 a 25% loading; between 15 and 24 years a 50% loading; and if you only join for the first time at age 60, there will be a 75% loading on your membership premium. This schedule of penalties is determined by the Medical Schemes Act.

Dependants

In order to qualify as a dependant of the main member of a medical scheme, a person has to be the spouse or life partner, or child (natural or adopted) of that member, or a person who is 100% financially dependant on that member. Most medical schemes will quote adult rates for anyone who is over the age of 21, even if that person is a member’s child and a full-time student, etc. A member may register a mother, father, brother or sister for whose care and support the member is legally liable, or who may be recognized as dependants in terms of a specific scheme’s rules. There are no limits on the number of dependants a member can register, but obviously the number will influence the membership premiums.

Different medical scheme options

Given that medical schemes are not allowed to discriminate in any other way, the only determinant of subscription quotes is the type of cover you wish to purchase, i.e. the plan or package. These may vary between basic cover on the one end, which will include prescribed minimum benefits (PMBs) and hospitalisation, and comprehensive medical cover on the other end of the scale, which will include 300% of National Health Reference Price List rates and a variety of other benefits, and a wide range of options in between. Most medical schemes will offer you the opportunity to request a detailed quote from their website or call centre, which will enable you to make an informed comparison.

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