Cape Town - Many people change medical schemes, or options within a scheme in the month of January.
While you are able to join a scheme any time during the year, or move from one scheme to another, changes to another option within a scheme can often only be done in January.
If you want to move schemes, there are quite a few things to remember. It is advised that you start getting your paperwork together long before the end of the year.
What if my schemes overlap?
You may not belong to more than one scheme at a time. This means that you have to give written notice (usually 30 days – but check with your scheme) of your intention to resign, before joining another scheme.
When does my cover stop?
Midnight on the last night of the month of which you still paid membership fees. If you were to need medical care on December 31, your old scheme will still be liable for costs incurred until midnight. At midnight, the new scheme will take over.
You still paid membership contributions for the last month, so you are still entitled to claim.
When can I submit my last claim to the scheme?
If your scheme stipulates that you have three months to submit your claims, you can still submit claims after you have terminated your membership – but only for medical treatment that you received while you were still a member.
So, if December was your last month, you can still submit claims for costs incurred during that month until the corresponding date in March.
Which papers will the new scheme need?
Your scheme must provide you or your dependant with a membership certificate within 30 days of the termination of your membership. This certificate must clearly state for how long you were a member of this scheme.
If you belonged to another scheme before, you may have to get a certificate from them too if you don’t already have one.
You will also have to fill in membership application forms and provide them with the specific documents they require.
What if my previous scheme no longer exists, or I am unable to get a certificate out of them?
A sworn affidavit must be accepted if reasonable efforts to obtain the membership certificate have been unsuccessful.
Why do I need this membership certificate?
In order to prove continuous membership of a medical scheme. If you are older than 35 and you are unable to prove continuous membership of a scheme from before April 1 2001, you may be charged a late joiner penalty.
Must I use a broker to join a new scheme?
No, you can contact the scheme directly (by telephone, online, or by mail) and you do not need to go through a broker.
Can my new scheme impose a waiting period on me?
Not with regards to prescribed minimum benefits, but they can impose a waiting period of three months for other claims if your membership has been interrupted or you have joined a scheme for the first time.
If you do not use designated service providers for PMB treatments, you can be liable for a co-payment.
A waiting period is a time when you are paying contributions, but cannot yet claim, except for PMBs.
What about exclusions based on medical history?
A new scheme can exclude you for a specific condition for a period of no longer than 12 months.
It is very important to be honest about your medical history, as non-disclosure is seen by the schemes as fraudulent behaviour.
So in a nutshell:
- Check out the different schemes and their options;
- Make a choice based on contributions, benefits and your health needs;
- Inform your scheme in writing of your intention to resign, or to move to another option as soon as possible;
- Ask for a membership certificate;
- Present this to your new scheme together with your application forms and other documents they request;
- Double-check telephonically with the scheme before the change-over date to make sure everything is on order;
- Submit your last claims to your old scheme;
- Remember to ask for a new membership card to be sent to you as soon as possible.
*Susan Erasmus is a freelance writer. Opinions expressed are her own.
Reference: Discovery Health; Fedhealth; Council for Medical Schemes