Medical Aid in South Africa: A Complete Guide
Medical aid schemes provide private health insurance in South Africa. They are regulated by the Council for Medical Schemes and governed by the Medical Schemes Act. Understanding how medical aids work will help you choose the right cover and make the most of your benefits.
What is a Medical Aid?
A medical aid scheme is a non-profit organisation that pools member contributions to pay for members health care costs. Unlike insurance companies, medical aid schemes are governed by the Medical Schemes Act and must offer certain minimum benefits to all members.
Medical aids operate differently from medical insurance products. Medical aids must pay for a Prescribed Minimum Benefits (PMBs) package regardless of plan type or premium paid.
If your medical aid refuses to pay for a PMB condition, you can complain to the Council for Medical Schemes. PMB cover is a legal right.
Prescribed Minimum Benefits (PMBs)
All medical aid schemes must cover PMBs for all members, regardless of which plan they are on. PMBs include:
- Emergency medical conditions (full diagnosis, treatment, and care)
- 27 chronic conditions including HIV, diabetes, hypertension, asthma, and epilepsy
- 270 defined diagnosis-treatment pairs for common conditions
- Maternity care
- Mental health emergencies
How to Choose a Medical Aid
There are over 20 registered medical aid schemes in South Africa, ranging from large open schemes to smaller restricted schemes (only for certain industries or employers).
Key factors to consider:
- Monthly premium versus out-of-pocket costs
- Hospital plan vs comprehensive plan
- Network hospitals and doctors (some plans require you to use specific providers)
- Chronic disease benefits for conditions you have
- Day-to-day benefits for GP visits, medicine, and optometry
- Gap cover products to top up your hospital benefit
- Financial stability of the scheme (solvency ratio)
Open Enrollment and Late Joiner Penalties
Open enrollment is when anyone can join a medical aid without being denied due to pre-existing conditions. Medical aids cannot refuse membership based on health status.
However, late joiner penalties apply if you join a medical aid for the first time after a certain age and have a gap in cover. The older you are when you first join, the higher the penalty loading on your premium.
There is no fixed annual open enrollment window in South Africa - you can join or change plans at any time. However, waiting periods may apply when you join a new scheme.
The Council for Medical Schemes
The Council for Medical Schemes (CMS) is the statutory body that regulates all medical aid schemes in South Africa. The CMS ensures schemes comply with the Medical Schemes Act and protects the rights of members.
If you have a complaint about your medical aid that cannot be resolved directly with the scheme, the CMS can assist.
- Website: www.medicalschemes.co.za
- Complaints: 0861 123 267
- Email: complaints@medicalschemes.co.za
- Physical address: Block A, Eco Glades 2, 420 Witch-Hazel Avenue, Highveld Technopark, Centurion
Medical Aid and the NHI
Under the NHI Act signed in 2023, once the National Health Insurance Fund is fully operational (targeted for 2030), medical aids will only be permitted to cover services not included in the NHI benefit package.
During the current transitional period, your medical aid continues to operate as normal. Continue paying your premiums and using your benefits as usual.