South Africa’s medical schemes have increased premiums and reduced benefits while complicating their offerings, making it difficult for consumers to find the best value for money.
The five biggest medical schemes — Discovery Health, Bonitas Medical Fund, Momentum, Medihelp and Bestmed — offer a range of hospital plans at varying prices for 2025, but financial advisers have warned that there are myriad pitfalls to watch out for when selecting an option.
These schemes have also implemented premium price hikes on plans ranging from 7.4% to 14.9% effective from 1 January.
Independent financial adviser Verona Pillay of ASI Financial Services highlighted trends such as a rising number of claims, increased medical costs and ageing memberships that have led to diminishing benefits.
To manage costs, medical aid schemes have gradually hollowed out benefits.
Pillay said five trends affecting members include:
• Higher co-payments: Many plans now require members to pay a portion of high-cost procedures, specialist consultations and diagnostic tests.
• Reduced day-to-day benefits: Out-of-hospital benefits such as GP visits and dental care have been cut in favour of hospital coverage.
• Network restrictions: Plans limit members to specific networks, reducing flexibility and increasing out-of-pocket expenses for out-of-network care.
• Benefit sub-limits: Hospital plan sub-limits for specific treatments, for example cancer care or prosthetics, are common.
• Higher premiums: Despite fewer benefits the premiums rise above inflation.
Pillay advised consumers to carefully consider their needs and the potential pitfalls of plans.
“Many plans have cut back out-of-hospital benefits such as GP visits, dental, optical and over-the-counter medication. The effect is that members are left paying for routine healthcare out of pocket, which reduces the perceived value of the plan,” she said.
The biggest pitfalls to watch out for when selecting a medical scheme are waiting periods, co-payments, benefit limits and exclusions and network restrictions.
“When deciding to pay a premium for a medical aid, consumers often overlook critical details that only become apparent when they face a health issue,” Pillay said.
Some schemes impose a general waiting period of three months when no claims are allowed except for prescribed minimum benefits (PMBs), while others may offer no cover for pre-existing conditions during the first year.
Co-payments and benefit limits could also leave consumers exposed as schemes often cover only a portion of the cost for hospitalisation, specialist consultations or procedures.
“For hospital admissions co-payments may apply for certain procedures, for example scopes, MRIs and elective surgeries, while benefit sub-limits include restrictions on coverage for high-cost items like prosthetics, specialised surgery, or cancer treatment,” Pillay said. “The effect is that members face significant out-of-pocket expenses,” she said.
Consumers may also not be fully aware of plan-specific exclusions or network limitations for certain treatments and high-cost drugs.
“Plans often restrict members to specific hospitals, doctors, and pharmacies [network providers]. Using non-network providers results in reduced or no cover,” Pillay said.
“During emergencies or complex treatments, members may find their preferred or nearest providers are not covered, leading to delays, stress or unexpected costs.”
Before choosing, consumers should also review waiting periods and plan for alternative coverage during that time.
Another crucial aspect of medical aid cover consumers need to be aware of is the law regarding chronic conditions and prescribed minimum benefits, because schemes sometimes neglect their responsibilities to pay for these treatments and instead claim co-payments from members.
Under the Medical Schemes Act of 1998 all registered medical schemes must cover 271 medical conditions and 26 chronic conditions, known as the chronic disease list (CDL).
The list includes 26 common illnesses such as hypertension (high blood pressure), diabetes (type one and two), asthma, epilepsy, hyperlipidaemia (high cholesterol), HIV/Aids and chronic renal failure.
“Whether you are on a hospital plan or a comprehensive plan, your scheme is legally required to cover the 26 CDL chronic conditions and the broader 271 PMBs,” Pillay said.
But if members choose a non-designated service provider they may face co-payments unless it’s an emergency.
“Treatment for chronic PMBs usually requires pre-authorisation and registration with the scheme’s chronic programme and members must adhere to the scheme’s protocols, such as using generic medications or following specific treatment plans,” Pillay said.
The Mail & Guardian explored the cheapest and most expensive hospital plans, as well as the cost of the top comprehensive cover, to find out where the pitfalls and value lie.
Here is a breakdown of what is offered by the country’s big five medical schemes.
By far the country’s largest medical scheme with 2 788 242 members and beneficiaries, Discovery Health offers its cheapest hospital plan, Active Smart, at R1 350 a month for the principal member. This is one of the cheapest on the market, but there are red flags.
This plan, targeted at active young professionals (although anyone is free to join), provides access to a limited network of private hospitals and co-payments may apply for certain procedures.
There is an extensive list of exclusions. For example, it does not cover hospital admissions related to investigations, dentistry, benign skin growths and lesions, as well as back, neck, knee and shoulder surgery.
The scheme’s most expensive hospital plan, Classic Core, is R3 652 a month and offers greater freedom of choice and wider cover for surgeries without hospital network restrictions.
The oncology limit for Active Smart includes only prescribed minimum benefits, which means the latest advanced treatments may not be available. The limit for Classic Core is R250 000. If the treatment costs more, a co-payment of 20% kicks in.
Discovery Health’s top comprehensive plan costs R11 430 a month.
There are no overall annual limits.
The scheme’s cheapest hospital plan, BonEssential Select, costs R2 192 monthly. It provides access to private hospitals within a designated network and includes preventative care benefits such as flu vaccines and screenings.
The Hospital Standard plan, at R3 252 a month, offers a more comprehensive hospital coverage without network restrictions.
On both plans oncology cover is unlimited for prescribed minimum benefits and there are co-payments of 20% to 30% for using a non-designated service provider.
On Hospital Standard there is an additional R168 100 per family for non-PMBs, with 20% co-payment once this has been reached.
BonComprehensive is the scheme’s top offering, priced at R11 321 a month.
There are no overall annual limits on any plans.
Momentum’s Ingwe plan, starting at just R589 a month for low-income earners, is the most affordable option among the top five schemes. But it is restricted to network providers and offers limited benefits.
The Evolve option is next-cheapest at R1 847 a month for the main member and offers some day-to-day benefits. There is no overall annual limit on these options.
Oncology is for PMBs only on the Ingwe plan while Evolve offers R200 000 per beneficiary a year at network oncologists, after which a 20% co-payment applies.
The scheme’s top plan is the Extender Option at R9 160 a month.
There is no overall annual hospital limit on any plans.
Medihelp’s MedMove! — priced at R1 638 a month — is a basic hospital plan with no overall limits.
At the other end of the spectrum is MedVital, which costs R2 244 a month for the network option.
Oncology cover on Medmove! is unlimited but subject to treatment protocols, which means some treatment may be excluded and comes with a 25% co-payment for deviation from these and a 30% co-payment for using non-designated service providers. Cover for oncology is R250 000 per family on Medvital.
The scheme’s top plan is MedPlus at R14 184 a month.
There is no overall annual hospital limit.
Bestmed’s Beat1 Network plan, at R2 111 a month, is a hospital-only plan with access to network providers. It includes maternity benefits and preventative care but imposes co-payments for out-of-network services.
The Beat4 plan, priced at R6 832 monthly, offers a combination of hospital and savings benefits with fewer restrictions.
Both plans pay 100% of the scheme tariff for oncology subject to treatment protocols at a designated service provider.
The scheme’s top comprehensive plan is Pace4, which costs R11 662.
There is no overall annual hospital limit on any plans.
According to the Council for Medical Schemes’s latest report for 2023 released in November, 71 medical schemes cover 14.7% of the country’s population, down from 16% in 2022.
The average age of the medical scheme population is 34 with almost 40% of beneficiaries living in Gauteng, underscoring the correlation between economic activity and medical scheme membership. Western Cape and KwaZulu-Natal came in second and third, with 15% and 14%, respectively.
Total healthcare expenditure on benefits paid in 2023 increased to R239 billion, up 9.44% from 2022.
