Investigating medical aid options can be difficult.
A guide of 10 essential tips on choosing a medical aid scheme to meet your needs and budget.
When choosing a medical aid scheme, you should consider:
- your budget, as you do not want to join and then resign because you cannot afford the plan
- understand your specific medical needs, including chronic conditions and family planning
- decide whether a comprehensive or hospital-only benefit plan (cheaper premium) will suit your needs
- use a broker like us strong>bestmedicalaid.co.za to understand the benefits, exclusions, and benefit limits
- Check the scheme's reputation, claims payment reliability, service quality, and solvency
- understand possible waiting periods and late joiner penalty implications
How to Choose the Best Medical Aid Plan in South Africa
Choosing the right medical aid plan to protect your health and budget can be complicated. There are 18 medical aids schemes from which to choose a plan, including well-known names such as Discovery Health, Bonitas, Medshield, and Fedhealth, among others.Each medical scheme has several plans to look at, all with different levels of benefits and limits.
Here is the best guide to choosing the right medical aid plan in South Africa.
Whether you are looking to join a plan or are an existing member considering switching to a new plan, this comprehensive guide will provide you with the tools and information you need to make an informed decision that will suit your unique needs and wants.Choosing the right medical aid plan is not just about your health, it's also about protecting your finances and ensuring peace of mind for you and your loved ones.
1. Understand the Types of Plans
Medical aid plans fall into two main groups:- Open Schemes: Anyone can join, no matter their health.
- Restricted Schemes: Only for certain groups, like employees of a company or members of a profession.
Comprehensive Plans which offer benefits for both hospital and day-to-day medical costs.
They covers things like hospital stays, doctor visits, and medicines.
The Traditional Comprehensive plan has set benefits and if you don’t use them up in a year, you lose them.
They are recommended for individuals or families who want predictable benefits for both everyday and major medical needs.
New Generation Plans with Savings offers a combination of in-hospital benefits and a savings account from which you pay all out of hospital costs like GP visits and medicine.
Unspent savings roll over to the next year.
If you spend all your savings, you self-pay costs for the rest of that year.
Some plans offer a safety net should you spend all your savings.
Joining a comprehensive plan may be best, if you have substantial day-to-day healthcare needs, because it will help you manage higher treatment-related costs.
Hospital-Only Plans cover you for hospitalisation, or emergencies and casualty. They don’t pay for day-to-day costs, however Genesis offers a hospital plan with both in and out of hospital dental benefits.
They are cheaper than comprehensive plans, so are attractive to healthy individuals who want protection against major medical events and are happy to self routine costs.
Hospital Plans with Savings, combine in-hospital cover with a savings account for routine costs.
These plans gives you a balance between cost and cover, allowing members to manage their everyday healthcare spending while being protected against high hospital costs.
Network Provider Plans use specified networks of hospitals, doctors, and pharmacies.
They are cheaper, and some have premiums based on your income.
However, they do limit your choice of provider and have several exclusions.
Network plans are ideal for those seeking affordable cover and who are comfortable using designated providers.
Emergency care is covered at any hospital, even if it’s outside the network
You do need to confirm that your preferred providers are part of the medical aid network before joining these plans.
Examples include Discovery Health’s Delta, Smart, Coastal, and KeyCare plans which each have their own provider networks.
Medical schemes offer different rates when paying in-hospital claims, to help you meet the difference in costs of private providers and the rate at which the medical aid pays claims.
Some plans pay up to 2 or 3 times the medical scheme rates, but they do cost more.
You can add a Gap/Top Up plan, to a lower-cost medical aid plan.
It will help you pay for in-hospital claim shortfalls (up to 5 times the medical scheme rat,) and have benefits to meet the cost of procedure co-payments.
That is unbeatable protection!
2. Decide on What You Need
Understanding Your Healthcare Needs
When looking for a medical aid plan it is important that you have a clear understanding of your healthcare needs.
You must consider factors such as your age, medical history, hereditary conditions and any existing and possible future health concerns.
Are you planning to start a family?
Do you require regular specialist consultations or ongoing chronic illness medication?
Does your family have hereditary conditions?
- Day-to-Day Costs:
Do you visit the doctor often?
Do you need dee regular medicine?
If yes, a comprehensive plan with good day-to-day benefits is recommended. - Hospital Cover:
Unforeseen accidents or illnesses can be very expensive.
Even if you self-pay for small things yourself, you do need good private hospital cover.
A hospital plan is the foundation of your healthcare cover.
If you self-fund your out-of-hospital expenses and join a hospital plan, you will reduce your premium (compared to comprehensive plan)
Now save those reduced premium amounts, and create your own savings fund, which can be greater than the day-to-day savings in a medical aid!
- Dental Costs:
Dental treatments are the second biggest medical cost we face.
Some hospital plans now include dental cover for emergencies. - Chronic Illness:
If you have a family history of illness, or need regular medicine, look for plans that cover these costs well. - High day-to-day medical costs:
If you often spend all of your savings, consider a plan with a bigger savings account or a safety net.
3. Think About Your Budget
Comprehensive medical aid plans are expensive, however there are plans designed for lower-income earners and that makes private healthcare accessible for those who could not normally afford medical aid.
These plans offer no overall limit hospitalisation, and provide mostly unlimited primary day-to-day care.
They ensure vital benefits for life-threatening situations like heart attacks, accidents, and life-sustaining conditions such as kidney or cancer illnesses.
Plans like: Momentum Health's Ingwe and Discovery Health's KeyCare plans.
Several plans provide good in-hospital cover and lower day-to-day saving funds, reducing your total contribution.
Fedhealth lets you manage your savings funds and controlling your premium, whilst giving you very comprehensive medical benefits.
Saving on Premiums.
If you join a hospital-only plan, you’ll pay a lower premium.
You can then use that money to build up your own day-to-day savings fund.
4. Check the Scheme's Claim Payment Record.
A medical aid scheme's good claim payment record is vital for its long-term sustainability and reliability.The Council of Medical Schemes is tasked with checking that schemes comply with solvency needs.
Schemes should have at least 25% of members' annual contributions in reserve.
Investigate the scheme's service quality by reading online reviews on sites like Hellopeter or My Broadband to see if members are happy.
5. Affordability.
Spent all Your Savings?If you continuously spend all your savings, you may need a comprehensive plan with a savings safety net.
These plans offer unlimited network GP consults and basic dentistry benefits, once savings are used.
Some plans extend your benefits (threshold benefit) up to a pre-determined amount, once savings are spent and claims have added up to a pre-determined amount.
Dependent benefits.
Some plans cover financially dependant children - at child rates - up to age 27
If you're not sure about which scheme suits you and your family best, we can help you look at the options that offer the most favourable rates for your family.
Get a Quote6. Overall in-hospital limits.
Hospital Limits.It is impossible to know what future hospitalisation may cost yo and you must consider plans with no overall in-hospital limits.
Co-Payments.
Most schemes levy defined procedure co-payments
Some can involve high amounts and you need to seriously consider a Gap/ Top up plan to help you meet these costs.
7. Choosing the Best Medical Aid to Suit Your Life Stage
In your 20's:
If you are a student consider the Best Student Medical Aid Plan.
A Very low premium, but with excellent benefits.
Or, because you have little need for doctor visits and medicines, consider a Hospital Only benefit plan.
Remember, we live in a violent country and you do need cover for emergencies, catastrophic events (big accident, illness or disease) and maternity.
You do not want to rely on your family to pay medical costs!
You are laying the foundation for your future health, so ensure you get preventative care benefits with your plan.
In your 30’s: look to an affordable family plan.
Families need more comprehensive benefits like hospital, GP, chemist, dentist and optical.
As these are more expensive plans, consider cheaper options that use network providers as these plans have discounted premiums.
Prevention is better than cure, and you need regular dental, cholesterol, glucose and blood pressure tests.
strong>Pregnancy is expensive and your plan must cover both pre and ante natal (as well as birthing) costs.
In your 40s, 50's and older, facing an increased risk of serious illness, the more cover you have, the better.
You need comprehensive benefits covering heart disease, cancer, osteoporosis and dread diseases along with good chronic medication benefits.
If you are prepared to use listed providers with a scheme, a network provider plan will have a lower premium.
Network options offer full cover for in-hospital treatments, including specialists, and day-to-day benefits, giving you a more comprehensive benefit than you might expect.
If you feel you do not need expensive day-to-day benefits, then consider a hospital only benefit plan.
Hospital plans provide the same in-hospital cover as most other, more expensive medical plans.They just do not cover out-of-hospital benefits like GP visits and optometry.
But, if you are a healthy person who visits the doctor or dentist once a year, that may not be such a problem.
Work out what you spend - out-of-hospital over a year - add 15% as a "bad luck" buffer and compare that amount, to the premium you save by joining a hospital only plan. I bet it will surprise you!
Here is a good medical aid blog to give you more valuable articles on medical aid.
8. Gap cover.
Private healthcare providers can charge up to 500% of medical scheme rates.Medical aids add procedure co-payments as well.
These are significant costs you must consider.
Protect yourself by joining Zest's GAP or top-up insurance plan.
This separate insurance will cover most in-hospital claim shortfalls and any co-payments. It is a vital safety net, ensuring you have enough to cover medical treatments, without having to pay for unexpected costs.Protect yourself from soaring medical expenses by bridging the gap between medical scheme rates and the charges imposed by private providers.
These are some of the claim shortfalls you could face:
| Not Fully Covered by Medical Aids | Shortfalls Paid by Gap Cover (ZAR) |
|---|---|
| Natural Childbirth | R 40,189 |
| Caesarean Section Childbirth | R 64,127 |
| Tonsillectomy | R 62,445 |
| Hernia Repair | R 57,236 |
| Breast Cancer Surgery | R 48,142 |
| Hip Replacement Surgery | R 58,143 |
| Spinal Surgery | R 62,901 |
| Cancer Treatment | R 146,240 |
| Heart Surgery | R 115,000 |
9. Exclusions and Waiting Periods.
Knowing what a medical aid does not cover is as important as understanding its benefits.
Plans can exclude pre-existing conditions, while others impose limits on payments for specific treatments.
Ensure you understand these exclusions and limits, before joining to a plan.
Upon joining a medical scheme, your application is underwritten and may have waiting periods imposed.
Anything from 3-months for everything, up to 12-months for specific conditions.
If you are already pregnant, the scheme will exclude your pregnancy for a year - but will cover your child from birth.
Lower cost plans have more exclusions like no joint replacements, specialised dentistry etc.
Specialised Dental treatments can be extremely expensive!
The costs of braces, root canal, implants and so on, can run into thousands of rand.Most treatments are done out-of-hospital, and are paid from your savings.
That can result in less money available for other medical needs and family limits being used on one member only!
Dental treatment is something we all need and it is vital you consider the Best Dental Insurance Plan
OR Most Affordable Dental Plan in South Africa.
No Medical Aid or have a Hospital Plan only?
This plan will help you meet the high costs of both normal and specialised dentistry!
10. Using a Broker
Brokers like ourselves offer valuable assistance in navigating the complexities of medical aid plans.
We will help you through the application process and answer any questions you may have.
And you don’t pay a cent for that service, whereas if you do go direct, you pay the same premium!
So, use use our skill and experience in this industry.
Investigating medical aid plans can be a challenge, especially if you are unfamiliar with the terminology used.
If you're feeling uncertain about your chosen options, contact us.
As a qualified medical aid advisor, we will provide personalised insights and recommendations based on your personal circumstances and priorities.
We will assist you in making an informed decision that meets with your healthcare needs and financial goals.
Complete the form on this web page and we will show you different plan types and costs, based on your needs.
Together we can identify plans that include in-hospital cover, coupled with a range of day-to-day benefits.And we charge nothing extra.
Yes, you pay what you would pay going direct. So, use us!
Your health is your most valuable asset, and investing in the right medical aid plan is an essential step towards safeguarding your well-being for the future.
Frequently Asked Questions: 10 Tips for Choosing a Medical Aid scheme
1. What types of medical aid plans are available?Medical aids are either open schemes where anyone can join, or restricted schemes for employer type groups only.
Each scheme offers various plans from traditional, new generation with savings, and network provider plans.
2. How do I choose a medical aid that best meets my budget and needs?
Start by looking at your past medical expenses, list recurring costs, and work out your budget. This will give you a foundation to further investigate plans that meet your specific medical needs and budget. The extent of the benefits you can get may be dictated by the cost of those plans.
3. How do I ensure the financial stability and reliability of a medical aid scheme?
Investigate a scheme's claim payment record, reserve levels, and service quality through the Council of medical Schema and platforms like Hellopeter. Look at what members are saying. Consider schemes with large memberships, as they provide enhanced financial security and are better suited to meet adverse health industry incidents, like pandemics.
4. Why should I look at overall in-hospital limits when choosing a medical aid plan?
Private care is very expensive and we do not know how high the cost of hospitalisation may be. It is important that your plan has no overall annual limits for hospitalisation. All plans have benefit sub-limits and procedure co-payments, so understand what they are.
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Last verified: October 20, 2025