Medical Aids in South Africa: A Guide to Selecting a Scheme

Medical aids, which are often a part of the cost of private health care for most South Africans, are not just an extra. As public hospitals are overcrowded, many people rely upon medical aid in order to get quality care, avoid long waiting periods, and pay for unexpected bills. Private medical aid schemes can work in conjunction with the state system and give families more options for doctors, specialists, treatment, etc.

This article will help you understand how South Africa’s healthcare system is structured, the changes that have been made to it for 2025, and what is driving prices up so much in 2018. This post will show you what to expect when it comes to different schemes. You’ll also learn which benefits are the most important to consider and how to pick a plan based on your individual needs. Here you will find facts, clear answers, and help in weighing your options.

Understanding medical aids in South Africa

South Africa’s private healthcare is based on medical aids. These groups help patients manage their hospital and other medical bills, which would be difficult to pay for out of pocket. South African medical help groups operate as non-profits, unlike some private health insurers in other countries. They collect funds, pool the money, and pay claims to those in need. The monthly contributions of each member help to create a safety network for all. This gives you peace of mind, whether or not you’re sick.

These schemes aren’t simply insurance products. They follow strict rules set out in the Medical Schemes Act. They are also supervised by the Council for Medical Schemes. These schemes offer a more structured package of benefits than public systems, which are often less predictable. There are many plans available for all budgets.

Open vs. Restricted medical schemes: Understanding the differences

Medical aid in South Africa is divided into two main categories: open schemes and restricted schemes.

Open medical schemes cover anyone who wishes to join them, so long as they don’t have another insurance plan in place and can afford the monthly payment. You do not need to work at a particular company or in a certain profession. Anyone older than 18 years old can apply. This is great for self-employed workers, families, and anyone who does not have access to a scheme offered by their employer.

Restricted Medical Schemes are available only to those who have a connection to a certain employer, group of professionals, or industry. A scheme may be offered to state employees, teachers, or factory workers. It could also be required for them to join. Since they have a regular, well-known group of members, these schemes offer lower monthly prices. You can’t join them if you aren’t a member of the related group.

Typical Members:

• People from all walks are eligible to be part of the Open Scheme. This includes freelancers as well as business owners and family members.
• Restricted Scheme members are usually big companies, groups of professionals, or industries that have large and stable workforces.

The Differences Between

• Accessibility: Open schemes = everyone; restricted schemes = industry/employer-specific.
• Price: Restricted schemes offer lower contribution rates due to a less volatile member group and reduced risk.
• Benefits:  Each scheme can have different extras.

How Medical Assistance Schemes Work

Medical aids, at their core, are systems of collective funding. These systems work based on pooling risk, where everyone contributes, and funds are used for those in need.

Here’s a breakdown of how it works in daily life.

• Members pay monthly contributions: The amount paid by each member is set. This is not profit. It goes into the pool to pay for current and upcoming claims. You’ll pay a certain amount depending on your age and how many people are covered.
• Nonprofit nature: South Africa’s law prevents medical aids from making a profit for shareholders. By law, medical aids in South Africa cannot make profits for shareholders. This helps to ensure that members’ money is put to work for them.
• Risk sharing: It is important to spread the risks. Healthy members, who don’t make many claims, help cover the cost of treatment for those who require expensive treatment. The system is sustainable and fair over time.
• Claims: The scheme receives a claim from the member or provider when the member needs treatment. If the service falls within the scope of the plan, it pays directly to the provider or reimburses the member.
• In private healthcare, medical aids are responsible for paying for treatment at private clinics and private hospitals. They do not pay public health care providers. For those with an active policy, this means shorter waiting periods and a wider choice of doctors.
• Medical aids are different from public health. All South Africans can use public hospital services, but medical aid members only have private cover. The policies are different from those of health insurance, which usually cover specific events and fixed payouts, but not ongoing medical care.
• Types and levels of coverage: Most schemes cover a wide range of packages from simple hospital-only to comprehensive packages which include specialist visits, chronic medicines, and wellbeing benefits.

Medical aid schemes make private healthcare accessible to more people by allowing them to share risk and funding. Choose the right type of scheme – open or limited, basic or extensive – to make a difference in your health.

Major Medical Aid Suppliers and Market Overview

South Africa’s medical aid market has been shaped by the well-capitalized plans of a small number of established companies. They offer different plans for budgets of all sizes and to meet individual needs. These providers, whose reputations are built on service for years, member growth, and product innovation, set the standard for private healthcare in South Africa. Let’s take a closer look at the major players to see what sets them apart.

Discovery Health – South Africa’s Largest Medical Aid

Discovery Health has a dominant position in the industry. They have approximately 1.36 million principal members and cover around 2.8 million lives by 2025. Discovery covers more than half of South Africa’s open medical aid market.

Discovery’s philosophy is to provide highly tailored options. Members can select from a range of menu options.

• Classic and essential plans (hospital or comprehensive option)
• Smart and KeyCare for affordable network-based healthcare
• Family cover with broad needs

Basic hospital cover starts at around R1,102 and goes up to R10,300.

Discovery stands out for its focus on technologies and wellness. Vitality is a famous program that rewards members who practice healthy habits. This includes regular checkups, exercise, and discounts on travel. The scheme is also the leader in digital healthcare tools, including telemedicine consulting and personalized app-based health tips.

Discovery’s main feature is:

• A large hospital network and specialist network
• The latest digital member portals for claims tracking
• Benefits of Wellness that can help lower costs
• High credit rating and reliable claim payments

Discovery’s focus on customer service and its rewards for healthy lifestyles allow it to be the industry leader.

Bonitas Bestmed & Other Leading Schemes

While Discovery may be the biggest scheme, many other restricted and open schemes are also important in serving South Africans.

Bonitas is Discovery’s closest rival among open schemes. It is estimated that Bonitas holds around 15% of the open market, with 730,000 principal members. Bonitas has a pragmatic approach, providing:

• From basic family plans (starting at R1,378) to comprehensive hospital coverage (up to R9,853), there are over 15 options.
• Chronic diseases: Strongly managed care
• Extras, such as free medication delivery, a child-focused program, or a baby care programme

Bonitas offers a great combination of value and coverage, making it the first choice for families and companies alike.

Which has over 200,000 primary members, is known for its emphasis on transparency in pricing and member services. Bestmed has a premium starting at R1,432.

• No or low co-payments to help members avoid surprises
• Easy selection of plans and easier claims
• Recognizing high levels of customer satisfaction

Medihelp and Momentum both offer a variety of plans to fit every budget. Medihelp provides coverage for over 90,000 primary members. Its competitive pricing starts at R750 (for basic cover). Momentum’s digital-first approach and Multiply wellness rewards attract younger clients and tech-savvy consumers.

Restricted Schemes as the Government Employees Medical Scheme Parmed, are important for those who qualify. GEMS’s large membership base provides dependable insurance that meets government budgets and needs. Parmed offers benefits that are tailored for certain professional groups, despite being smaller.

These big names share many similarities:

• All maintain strict solvency ratios, ensuring claims get paid.
• Each plan offers options to meet a variety of health needs.
• Service quality is a priority, as are user-friendly requests, approvals, and support.

• What are your specific needs? (Family, chronic condition, network preference).
• Budget
• What you need to know if you want to apply for a restricted plan

These providers set the benchmarks in terms of digital access and value. They also offer personalized benefits to South Africans who want the best possible health cover.

Framework for Regulation and Legal Guidelines

Be sure to read the rules of the road before selecting a plan. Medical schemes are regulated in South Africa by the Council for Medical Schemes and must follow the strict laws laid out in the Medical Schemes Act. These laws are in place to protect your rights, ensure fair play, and keep medical assistance schemes stable and honest. Understanding these rules allows you to see the structure of your plan, the minimum coverage that you can expect, as well as how your interests will be protected no matter what scheme you join.

Prescribed Minimum Beneficiaries (PMBs) and Mandatory Coverage

In the Medical Schemes Act, it is stated that all registered medical aids must cover prescribed minimum benefits (PMBs). The PMBs package includes benefits such as emergency treatment and specific in-hospital services.

What is covered by PMBs? 

• This list contains 271 medical conditions that include emergencies.
• You can find out about 26 chronic conditions like diabetes, asthma, and hypertension.
• If your health or life is in danger, emergency medical treatment may be necessary.

Medical aids must pay for all treatment, no matter which plan you are on. This includes the most affordable hospital-only plans. These benefits are meant to protect you from being left behind in a medical emergency.

PMBs can act as a safety net for you by:

• The blocking schemes prevent you from having to pay out of pocket for essential, life-saving treatment.
• Make sure everyone in all schemes receives the basic protection.
• If you find yourself in a hospital due to a PMB, it is important to ensure your right to necessary care.

For full coverage, it is important to check the network of doctors and hospitals that your PMB scheme uses. Be sure to ask your doctor about PMBs before treatment.

Financial Reserve Requirements and the Scheme Government

The medical aid scheme can’t simply collect money and hope that it works out. The law specifies a minimum amount of money that each scheme should reserve, also known as reserves. This is to cover the care claims when members need them. This financial cushion ensures the security of schemes and protects their members.

South African rule:

• A minimum of 25% of gross annual contributions must be held in reserve by every scheme.
• The CMS receives a monthly report from the Schemes on this reserve ratio.

Why are reserves important? These reserves are the scheme’s safety net. Even if the number of claims is higher than expected (due to a bad pandemic or flu season), the scheme pays out. It prevents schemes from running into financial problems and ensures that they are available when needed.

Scheme management is also important. All schemes must:

1. Be overseen by a Board, made up of members who are elected by them and represent their interests.
2. Medical Schemes Act and approved Scheme rules.
3. CMS requires that you submit regular, audited reporting to them for review.
4. Clearly and in everyday terms, disclose all benefits, exclusions, and changes.

Trustees are in charge of making important decisions about contributions, benefits, and management. The CMS oversees everything and can intervene when there are complaints made or concerns raised about the operation of a scheme.

Scheme governance includes:

• Transparency is required in the fees, rules, and benefits.
• You can also vote or raise any issues at the regular meetings. 
• No discrimination based on age or condition.

These laws and check-ups aren’t just paper. It means your medical assistance is not designed for the scheme to make money, but rather for you. Knowing this framework allows you to have confidence in the safety of your membership and funds.

How to Select the Right Medical Assistance Scheme 

Picking the cheapest option is not the only way to find the best medical assistance. It’s important to compare what you pay with what you get. Make sure you are covered for the expected as well as the unexpected. The jargon can make it seem overwhelming. There are dozens and dozens to choose from. We will break down the options by looking at plan types, track records, real-world effects, network coverage, and additional coverage.

Finding the right plan for you

Not all medical plans offer the same coverage. What’s best for you will depend on your health, family situation, and budget. Let’s take a closer look at three of the most popular plan types:

• Hospital Plan: These plans only cover in-hospital care and emergency treatments. You must pay for all doctor visits and medications. It is good for young, healthy individuals or families who seldom visit the doctors but want to avoid large, unexpected bills.
• Comprehensive plans: As well as hospital cover, they also include chronic medications and specialist visits. They may even include dental or optometry. The plans are suitable for families, chronic disease sufferers, or people who do not like to pay out of pocket for medical care.
• Combination plans or network plans: They provide limited coverage day-to-day, as well as hospitalization. However, they are only available if you choose preferred providers. You can save money if your plan includes doctors and hospitals.

What should I pick?

• You can usually get away with a basic hospital insurance plan if you’re single, young, healthy, and want to save money.
• Consider a strong combination or comprehensive coverage if your family has children, you need regular medical care, or you suffer from a chronic disease.
• For those who want to keep costs down and don’t mind following a list of doctors they know well, network plans can be a good option.

Assessing the financial health of schemes and service quality

It’s very easy to get distracted by flashy ads and long lists of benefits. However, the real test for a scheme is whether it can pay out your claims, and how easy it makes the process. What matters is:

• Schemes Size: Larger plans like Discovery or Bonitas offer a greater choice of hospitals and doctors, as well as more stable premiums.
• Ratio of Reserves: This represents the cash cushion set aside by the insurer to pay claims. The law requires that this buffer be at least 25%. Higher reserves are a sign of a safer and more reliable scheme.
• Claim Payout Histories: Check to see if there is a pattern of the scheme being known for slow processing claims, refusing them, or not honouring their contract. Pay attention to schemes with a track record of paying on time and in full.
• Digital Service and Tools: A good scheme offers easy ways to submit a claim online, track the approvals, and talk to a consultant in a short time. Top schemes are expected to offer apps for claims, virtual consults, and online benefits breakdowns in 2025.

TIP: Ask around for feedback on customer service and read reviews of the scheme.

Additional coverage, provider networks, exclusions, etc.

The fine print is always included in any plan. Understanding what you’re covered for, who is allowed to visit, and what costs are not included is essential.

• Providers Networks: Most plans (especially those with lower premiums) cover only doctors, hospitals, or specialists that are part of their “network”. Any care outside the network can be expensive.
• Cost-sharing: Despite having health insurance, you may be asked to cover a certain amount of the cost (such as for certain medicines or MRIs). You should know these numbers up front to avoid any unpleasant surprises.
• Coverage Exclusions: Some therapies, medications, or treatments may not be covered. Be sure to check the exclusions before seeking medical attention.
• Coverage for the Gap: Medical aid schemes can’t cover all costs, especially with specialist doctors who charge above the medical aid rate. Gap coverage is a policy that will cover these gaps.

What you should check before joining:

• Are your local doctors or hospitals included in the network?
• The list of excluded treatments in the plan–does that affect your family members?
• What are the copayments for scans, specialist visits, or chronic medications, and what is their limit?
• Can you bridge gaps with gap cover, and how much?

Not just the documents, but also your peace of mind, is important when choosing a medical aid. Do not hesitate to ask specific questions and to compare the benefits of different policies.

South Africa’s Future Medical Aids

South Africa is poised to experience a major healthcare revolution. The decisions that people are making today regarding medical aids may feel very different in the next few years as public policies and technology change how health care is delivered. Medical aids are facing a new era of reform, with tighter budgets and more intelligent ways to manage your health.

The National Health Insurance Bill

National Health Insurance (NHI), a bill that will be introduced in South Africa, is expected to revolutionize the way South Africans obtain healthcare. The plan was bold–one single national fund run by the State, pooling resources to provide quality healthcare for all without large out-of-pocket costs. After the NHI has been fully implemented, private health insurance will only be able to cover services that are not paid for by the NHI.

The private medical aids are affected by this:

• Scope reduced: NHI won’t pay for medical aids that duplicate the NHI. The future role of medical aids may be to offer supplementary or “top-up” cover for private room, dental, or specialist services outside the basic package.
• Fewer members: As NHI expands, fewer individuals may need private coverage. Medical aids are then forced to adjust or shrink their pool.
• Pricing and Value Rethink: When the state handles big-ticket health care, private plans will need to compete based on extras.

The rollout continues to be in flux as it faces funding challenges, court battles, and discussions. Some groups say that these limits may limit the choice of citizens and retard private sector innovations. Watch out: When and how NHI replaces core service remains an ever-changing target, but it will have a huge impact.

Evolving Consumer Choices and Needs

Medical aid has changed the way that people think and act. Cost of living increases, increasing unemployment, and successive contributions increases have forced many people to downgrade their plans. Due to tight budgets, even middle-class households are choosing basic hospital plans with network-only benefits and ditching the extras.

This is what drives new choices:

• Flexible coverage: Increased interest in modular, microinsurance, and other products that allow people to only pay for what they need.
• On-demand Health: Due to their busy schedules, people are looking for health care that is convenient. They want instant virtual doctor visits and quick pharmacy care.
• Mental and Chronic Care: As mental health care needs are becoming more prevalent and chronic disease burdens are increasing, it is important to provide a fuller and more targeted treatment.
• Transparency & Trust: Schemes that make the terms, limits, and exclusions clear win more loyalty. No one wants the hassle of reading fine print when a crisis occurs.

In order to meet this shift, medical aids will need to be agile. They must offer members more choice, reduce paperwork, and provide better digital service.

Technological Innovation and Digital Disruption

Digitalization has revolutionized private healthcare. Innovative medical aids are racing each other to release tools and features that make life and claims easier. How tech is changing the medical assistance game

• Telemedicine: Video visits with doctors and instant chats between nurses and rural members reduce travel and waiting time and costs.
• Data-driven Customization: Apps for health, online risk calculators, and wearables can help create personalized benefits. They also reward healthy habits and manage chronic diseases better.
• Smart Claim Processing: AI, automation, and blockchain technology make it easier for claimants to track their claims, to settle them more quickly, and to detect fakes. This reduces the costs for everyone.
• Virtual health ecosystems: A growing number of schemes tie together doctors, hospitals, pharmacies, and specialists with one platform or app, providing members a clear way through the systems. There are no more scattered test results or scattered records.

What are the results? Smart use of the technology allows you to take control, making cover easier, more useful, as well as cheaper.

What to watch for: Opportunities and Challenges

Not everything will be as smooth as it sounds. There are obstacles. 

• There are still many public hospitals that have staff shortages. They also suffer from long queues and outdated equipment.
• A possible increase in taxes could be used to fund universal healthcare.
• Private schemes might shrink, but they can also reinvent themselves into elite, ultra-customized services if you want more choice than NHI.

When looking for an opportunity, you should:

• All products will be more affordable to gig workers, entrepreneurs, and those in the informal economy.
• Partnerships expanded between public and private schemes, sharing resources and knowledge.
• Governments and consumers will be more focused on long-term healthcare and prevention.

Change is here. In the new age, those schemes that listen to their members, adapt quickly, put them first, and place them at the forefront will succeed. South Africans will be the true winners if they want affordable, easy-to-use, and honest healthcare, no matter what happens with policy next year.

You will be able to conclude your conclusion by clicking on the link below.

Selecting the best medical aid is about more than simply choosing a plan off a menu. South Africans have to deal with some of their biggest price increases since years. New rules, changes in benefits, and pressures on the budget are all contributing factors. The real-world value is what you will get from your money.

It is important to know your most pressing needs, the financial stability of the plan, and what coverage is available. Matching your insurance to your lifestyle will help you feel more confident, especially in a year of double-digit increases.

Review and compare your options before you commit. Don’t rush. Ask questions, speak to your healthcare provider, and consider new trends such as telemedicine or digital tools. Your wallet and your health are worth it.

You’re welcome. Tell us below if you enjoyed this guide or have an experience to share on how to find the right plan. Your opinion can help others, too.