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How Medical Scheme Membership Works

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Medical schemes in South Africa are governed by and operate in terms of the provisions of the Medical Schemes Act 131 of 1998 and are regulated by the Council for Medical Schemes (CMS). These schemes operate as non-profit organisations overseen by a board of trustees and are required to be registered with the CMS. The schemes don’t have shareholders or distribute dividends. Their income solely comprises member contributions and investment returns. All contributions from members are pooled to cover claims with any surplus funds allocated to scheme reserves in compliance with the relevant regulations. The legislation is aimed at ensuring the security and welfare of contributing members.

Medical aid companies do not generate profits but solely serve their members by pooling and protecting funds to cover claims based on the scheme’s guidelines and rules. Schemes are focused on providing fair and equitable care for all members in accordance with their chosen benefit plan.

 

Membership of Multiple Medical Schemes at the Same Time

Why would one wish to belong to more than one medical scheme at the same time? Perhaps the most common reason for wanting to be a member of more than one medical scheme at a time would be to obtain broader coverage for medical expenses, as different schemes may offer different benefits, including access to different networks of healthcare providers and services. A particular scheme may cover specialised services or treatments that others do not cover, and multiple memberships may provide access to those services.

Another reason that one may want more than a single membership is to ensure that, should one scheme experience financial difficulties or undergo changes in coverage, the other scheme will provide continued access to the desired healthcare services.

Section 28 of the Medical Schemes Act 131 of 1998 prohibits the joining of more than one scheme at a time. So, despite the perceived potential benefits, this is not an option. All medical schemes in South Africa will enquire whether potential members applying for membership are currently or have been members of another scheme. Failure to answer this question honestly with the intent of gaining membership in more than one scheme is illegal and may result in possible criminal prosecution.

 

Increased Costs the Probable Result

Even if multiple memberships were permitted, joining more than a single medical scheme at a time would likely result in increased costs. Dual membership would mean two sets of administration costs while paying premiums for each scheme. This would probably result in higher overall healthcare expenses compared to being a member of a single scheme. There may be instances where both schemes cover the same medical expenses, leading to redundant coverage and once again unnecessary costs. Managing multiple schemes would require coordination of benefits, submitting claims to different insurers, and keeping track of coverage details from each scheme.

 

Dual Membership Prohibited but May Happen

You might find yourself in a situation where you’ve been a member of one scheme, subscribed to by your current employer, and you’re now on the verge of joining a new company that uses a different medical aid provider. Under these circumstances, it’s understandable that there could be a brief period of overlap in your membership between one scheme and the other during the transition period. This should be temporary and of short duration.

The temptation to retain membership in one scheme and join a second to fund claims from the second scheme’s benefits because the medical savings account of the first scheme has run out, or reached the self-payment gap, is illegal and may constitute fraud.

 

Group Schemes

In the past, medical aid membership was mostly restricted to persons working for larger corporates in South Africa. Membership was (and still is) primarily an employee benefit where the employer subsidised the member’s monthly contribution to make medical cover more affordable. People who worked independently, outside of corporate organisations, seldom had access to medical aid unless they belonged to a recognised profession. Legal and medical professionals, for instance, have access to medical schemes that are exclusive to their profession.

 

Affordable and Comprehensive Medical Aid for Private Individuals

Fortunately, there are affordable medical schemes available to private individuals and group schemes are no longer the only option. KeyHealth provides affordable medical aid and healthcare management services in a transparent and client-centric manner. Our comprehensive range of products suits most needs and one of our medical aid options is bound to suit you. For more information, contact Keyhealth today and get affordable, high-quality medical aid.

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