Summary of waiting periods and late-joiner penalties

 

Below is information about the waiting periods and late-joiner penalties.

Type 1 membership

This category pertains to individuals who either have no prior medical coverage or have experienced a gap in their coverage that exceeds three months from their previous medical scheme. Such individuals may face specific waiting periods and limitations in terms of coverage eligibility.

Type 2 membership

Type 2 membership applies to those who have had less than two years of continuous medical coverage, provided that they have not had a break in their coverage that exceeds three months from their previous medical scheme. This classification may come with certain waiting periods and conditions that need to be met before full benefits can be accessed.

Type 3 membership

Individuals who have maintained more than two years of continuous coverage, with no more than a three-month break from their previous medical scheme, qualify for Type 3 membership. This type generally offers more favorable terms regarding waiting periods and coverage eligibility.

Waiting periods that may be applied:

Type 1 membership

Members classified under Type 1 may face a 12-month waiting period for specific conditions, along with a general waiting period of three months. This means that for certain pre-existing health conditions, members will need to wait a full year before they can receive benefits related to those conditions, in addition to the initial three-month waiting period for general coverage.

Type 2 membership

For Type 2 members, there is a 12-month waiting period for any newly diagnosed conditions. Additionally, they may also need to fulfill the remaining waiting periods that were still active from their previous medical scheme. This can affect their access to certain treatments or services until the waiting periods are satisfied.

Type 3 membership

Type 3 members will typically only experience a three-month general waiting period. This relatively short waiting period allows them to access most of the benefits sooner compared to other membership types, making it a more advantageous option for those with a stable coverage history.

Prescribed Minimum Benefits:

Type 1 membership

Unfortunately, individuals with Type 1 membership are not eligible for coverage of Prescribed Minimum Benefits. This means that they may not receive certain essential health services that are mandated by law for all medical schemes.

Type 2 membership

Members classified as Type 2 are eligible for coverage of Prescribed Minimum Benefits. This provides them with access to a range of essential health services that are crucial for maintaining their health and well-being.

Type 3 membership

Similarly, Type 3 members are also eligible for coverage of Prescribed Minimum Benefits, ensuring that they have access to necessary health services without significant financial burden.

Late-joiner penalties

A late joiner is defined as an applicant or dependent who, at the time of application with Momentum Medical Scheme, meets any of the following criteria: they are 35 years or older, were not a member of a registered medical scheme on or before April 1, 2001, or have allowed a break in their membership that exceeds three months since April 1, 2001. These criteria are important as they determine the penalties that may apply when joining the scheme later in life.

How to calculate the late-joiner penalty:

The formula to calculate the late-joiner penalty is as follows: A = B - (35 + C), where B represents the applicant's age and C denotes the creditable coverage, which is the number of years spent on a South African registered medical scheme. This calculation helps to determine the additional costs that a late joiner may incur when enrolling in the medical scheme.

The late-joiner penalty is applied to the risk portion of the contribution and is based on the following scales:

Years not covered on a previous medical scheme from age 35 onwards -- Late-joiner penalty

• 1 - 4 years: 5%
• 5 - 14 years: 25%
• 15 - 24 years: 50%
• 25+ years: 75%

This tiered penalty structure means that the longer an individual has gone without medical coverage after turning 35, the higher the percentage of the penalty they will face when joining the Momentum Medical Scheme.