Time to Review your Medical Aid

Did you know that you are allowed to change your medical aid schemes from one benefit option to another once a year, either in November or December. Most medical aid companies will allow you to change plans or options without penalties.

Between October and December every year, you have the option to change your cover options within your medical scheme. Although you can change from one medical scheme to another at any time, you only have this ±6 weeks window to change your cover options within your existing medical scheme.

Now is the time to review your current medical cover and decide whether you are on the right plan.
Here is a guideline to help you make this decision:


Most of us can simply not afford a plan that covers every imaginable medical expense. You have to choose a plan with affordable monthly premiums that will cover a sufficient portion of your expected medical costs.

Medical schemes have released their respective premium increases for 2019 and they vary between 8% and 11% depending on your scheme and plan. If your medical scheme has not communicated your increase to you, now is the time to contact them and ask. Medical aid inflation is above inflation and could be above your salary increase so make sure to factor that into your budget for 2019.


Choosing between a hospital plan and a comprehensive plan is one of the most important decisions that you will have to make.

Hospital Plans

A hospital plan is an affordable option that covers most of your large or unexpected medical costs. This option is the most popular among medical scheme members in SA.

A hospital plan typically only covers in-hospital expenses, emergencies and the list of conditions that is covered by the scheme’s Prescribed Minimum Benefits obligation. A hospital plan will not cover any other expenses such as doctors’ visits, medication, dental expenses, optometric expenses, therapy, etc.

Comprehensive Plans

A comprehensive plan covers everything that a hospital plan covers, plus some out-of-hospital expenses.

Each medical scheme usually offers many different hospital and comprehensive plans, and each scheme’s plans are usually unique to that scheme. This makes it very hard to compare options and choose between plans, but doing so is highly recommended. There are some online medical scheme comparison tools available, such as Hippo, Rehealth and IFC that might help you to compare the options.

Co-payments, scheme rates and formularies

Sometimes, your medical plan will require a fixed co-payment from you when you incur medical expenses that are covered by the scheme. Co-payment amounts vary between schemes and plans and you should familiarise yourself with these to avoid unpleasant surprises.

Medical schemes also have so-called “scheme rates” which serve as a baseline for consultations, procedures, medication, etc. The scheme’s contribution towards these expenses will depend on the plan that you have selected. For example, the scheme may cover your doctor’s rates up to 100% of the scheme rate when you are on an entry-level plan, but up to 200% or more when you are on a more expensive plan. Many specialists and medical service providers charge much more than the scheme rates and could require large co-payments from depending on your plan.

Each medical scheme also draws up a formulary, which is a list of safe and efficient medication that they have approved for treatment of certain conditions. When you purchase medication, your scheme may only pay up to the price of the medication on their formulary. You will then have to pay the difference out of your pocket.

Medical Savings accounts

Some plans will include a medical savings account, which is a dedicated account used for your day-to-day medical expenses such as doctors’ visits, medication, dental expenses, optometric expenses, therapy, etc. A fixed portion of your monthly contribution, depending on your plan, will be allocated to your medical savings account.

Plans with a medical savings account are usually much more expensive than others. Some schemes have loyalty programs that will pay cash rewards into your medical savings account.

Designated Service Providers (DSPs)

Sometimes, more affordable plans will only cover your expenses when you use a healthcare service provider (doctor, hospital, pharmacy, etc.) that is listed as a DSP of the scheme. These DSPs are the scheme’s first choice when it comes to the diagnosis, treatment or care of medical conditions. DSPs are usually grouped in a certain geographic area or they charge lower tariffs than other service providers.

If you choose not to use the DSP nominated by your scheme, you may be liable for a co-payment.

Prescribed Minimum Benefits (PMBs)

Prescribed Minimum Benefits are a list of benefits that all medical aid members must have access to, regardless of the plan that they have selected. This means all medical aid members must be covered in full for the costs related to the diagnoses, treatment and care of:

Any emergency medical condition;

A limited set of 270 medical conditions; and 25 chronic conditions. Here is a list of the Categories (Diagnosis and Treatment Pairs) constituting the Prescribed Minimum Benefits (PMB) Package under Section 29(1)(o) of the Medical Schemes Act (listed by Organ-System chapter).

Medical schemes may manage the costs of these PMBs by insisting that the member be treated with medication listed on their formulary.

Chronic Conditions

Depending on your scheme and plan, some chronic conditions will be covered in addition to the 25 PMB chronic conditions. If you or one of your dependents suffer from a chronic disease, make sure you familiarise yourself with the chronic conditions that your plan covers. Keep in mind that there may be hereditary chronic diseases in your family that you should be covered for, even if you don’t have any symptoms yet. You should do your research and shop around for a plan that covers your chronic needs.

Gap cover

Gap cover is a medical insurance product that works in conjunction with your existing medical scheme. You cannot have gap cover if you are not a member of a medical scheme. The purpose of gap cover is to cover the difference between what the medical service provider charges and what your medical scheme is willing to pay.

It is important to understand that gap cover will never cover an expense that is excluded by your medical scheme. Gap cover only tops up the shortfall when your medical scheme makes a payment on your behalf.

We know it is not easy to choose the right medical scheme and plan, but it is definitely worth the effort and time