10 Tips for Choosing a Medical Aid (in South Africa)
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Investigating medical aid options can be difficult to do.
Let us guide you through 10 essential tips to make your decision easy and help you choose the best medical aid scheme to meet your needs and budget.
Otherwise, finding the best plan within your budget is important.
This guide offers advice and tips when choosing and joining the best medical aid.
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.
What type of cover is there?
You need to begin with identifying your needs and wants that an ideal plan for you must cover.
Understanding Medical Aid Options:Medical aids fall into 2 categories: open medical schemes (everyone can join, irrespective of health status) and restricted medical schemes (open only to specific groups, like employees or profession-based memberships).
Medical aid plans comprise of:
- Traditional plans
- New Generation plans with savings
- In-Hospital only plans
- In-Hospital plans with day-to-day savings
- Network Provider medical aid plans
These categories help you to choose plans because they involve your budget, healthcare needs, and list the pros and cons of each plan.
You may be able to self-fund daily out-of-hospital expenses, but cover for major incidents or diseases is essential as they can be very expensive.
An in-hospital-only plan can greatly reduce your premiums, when compared to a comprehensive plan.
There is a hospital only plan that also pays for essential dentistry, taking care of dental emergencies like fillings and extractions, all in one plan!
Investigate the different types of medical plans on offer, such as traditional, new generation with savings, hospital only, hospital with day-to-day savings, and network provider medical aid plans.
To meet the possibility of having to pay for major accidents or illnesses, the choice between comprehensive plans, (offering in and out of hospital benefits) and hospital-only plan, (where out-of-hospital costs are self-covered) is important.
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.
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!
Different plans use networks of healthcare providers, which may affect the level of care you receive.
You do need to confirm that your preferred providers are part of the medical aid's network before joining a plan.
Your health is of great importance and the difficulty of choosing a medical aid plan, from all the plans available is a concern.
We aim to help you find the perfect plan to ensure your peace of mind.
Your current healthcare needs, past treatments and costs.
Understanding your present healthcare needs and past treatments is important when looking for the most suitable medical aid plan.Past Medical Expenses:
Look at your past medical expenses like hospital, dental, specialist, doctor, medicine, and optical costs.
Whilst day-to-day medical treatment might not be that frequent, preparing for unforeseen high private hospitalisation costs is extremely important.
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!
Your Specific Needs:
Consider any hereditary conditions or familial illnesses like glaucoma that might require comprehensive benefits for associated expenses. look at network providers for chronic medicines as they might offer discounted premiums.
Recurring Medical Costs:
Anticipate recurring expenses like flu incidents and consider the possibility of spending all your day-to-day savings throughout the year.
If this is a concern, a plan with a higher savings may be your answer?
Dental Costs:
These are probbably the second highest type of cost we face. Can you manage to pay your own dental expenses?
If you can, an in-hospital plan may be your best affordable plan.
if not, there ia a hospital plan that covers dental costs, providing you with comprehensive benefits and peace of mind, all in one plan!
Affordability.
The best medical aid plans are expensive, however there are other plans designed for lower-income earners. That makes private healthcare accessible to many people, 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.
Certain plans provide good hospital cover and lower day-to-day saving funds, which reduces your total contribution.
Fedhealth lets you manage your savings funds, whilst giving you very comprehensive medical benefits. And that results in substantial premium savings!
Spent Savings:
If you continuously spend all your savings, you may need a plan with a safety net. These plans offer unlimited network GP consults and basic dentistry benefits, once savings are used.
Some plans extend your benefits 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!
Hospital Insurance Plans:
Hospital insurance plans, which pay a daily rate for hospitals, may not cover a great part of your medical costs, reinforcing the need for comprehensive benefits. We do not recommend these plans!
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.
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.Examining a scheme's claims and reserves is essential to gauge its ability to meet financial obligations and promptly pay claims.
Asking your GP or nearby private hospitals about their experiences with specific medical aids' claim pay-outs can be useful.
Platforms like Hellopeter or My Broadband can offer valuable insights into any administrative or service-related concerns shared by current members, indicating the scheme's service quality.
A scheme with a solid servicing record is undoubtedly preferable.
Our Commitment to Your Safety:
We are dedicated to guiding you away from financially unstable schemes. Using our experience, we aim to present you with large membership schemes, typically offering greater financial security. Larger schemes can better withstand member loss impacts on their solvency, compared to smaller ones.
Avoiding schemes who lack financial soundness, is our priority.
A scheme with large membership is more secure. If they lose 1,000 members, the effect on their solvency will not be as great as a small scheme that loses the same number of members.
Let us help you discover that scheme!
Overall in-hospital limits.
It is impossible to know what future hospitalisation may cost you.Certain plans impose overall limits on in-hospital treatments, while others may restrict specific treatments like surgeries or cancer treatments.
You should consider plans with no overall in-hospital limits if you want comprehensive benefits.
In 2024, a day in intensive care cost approximately R57,000. For a family of four, this amounts to R228,000 per day or R1,5mil over a week.
So, a no overall annual limit on in-hospital benefits plan is highly recommended.
Although a plan might have no overall limit, sub-limits can still apply - as per the listed rules. These sub-limits can restrict certain claims and result in co-payments that you must pay. For example, with unlimited cancer cover, there might be a predefined amount after which a co-payment is levied.
Check the HIV cover as in South Africa, this is important. What a scheme will pay should you become HIV-positive and, maybe require a lengthy hospital stay, or on-going chronic medication is important.
Choosing the best medical aid plan.
This all depends on your individual needs and budget.
In your 20's:
If you are a student consider the Best Student Medical Aid Plan. 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 plan for a family.
Families need more comprehensive benefits like hospital, GP, chemist, dentist and optical. These are more expensive plans, sot consider cheaper options that use network providers. Manny of these plans are discounted.
Prevention is better than cure, and you need regular dental, cholesterol, glucose and blood pressure tests.
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: with an increased risk of serious illness, the more cover the better.
You need comprehensive benefits covering heart disease, cancer, osteoporosis and dread diseases which develop later in life, A plan 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.
However, because you can only use certain healthcare providers, this may be a concern?
If most of the listed network providers are easily accessible, then it’s a perfect match.
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.
INGWE Network Medical Plan - This plan offers an ANY hospital option as well!
KEYCARE Network Medical Plan - the most popular plan in South Africa.
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.
Because a hospital plan is much more affordable than a comprehensive medical plan, you can use that saving in contribution, to pay for your out of hospital expenses. It may still be cheaper, over a year than joining a comprehensive medical aid!
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. Gap/top-up cover is the most affordable way to supercharge your current medical aid plan - at far less cost than upgrading it! Gap cover is a type of insurance that covers the difference between what your medical aid pays for in-hospital treatment and what the healthcare provider charges. Schemes are increasingly adding procedure co-payments, which a top-up pays as well. Premiums for a good top-up are around R 350 pm and you can buy from any company you want. For more detail on this very valuable addition to your medical cover plan, please read The Valuable Benefits of top-up/Gap cover Insurance. Dental treatment is something we all need and it is vital you consider the Best Dental Insurance Plan OR Most Affordable Dental Planin 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! Knowing what a plan doesn't cover is as important as understanding its benefits. Some plans exclude pre-existing conditions, while others impose limits on payments for specific treatments. Ensuring clarity on these exclusions and limits is vital before committing to a plan. When you join a medical scheme, your application is underwritten the scheme and it may add waiting periods. If you are already pregnant, the scheme will exclude your pregnancy for a year - but will cover your child from birth. You must be a member at that time. Lower cost plans have more exclusions. Joint replacements, specialised dentistry etc. are not covered. Be aware of these possible exclusions before joining by making a point of reading the plan rules! So, use use our skill and experience in this industry. Talk to me .... I am here to help you - at no charge! You must consult the schemes/company product brochures and rules for comprehensive benefit descriptions. We will offer you the best help at no cost! Disclaimer, Medical Disclosure South African rights reserved. Last update: January 18, 2025Gap cover.
This can be particularly useful for expensive treatments such as cancer or major surgery where the costs can be significant.
top-up insurance is a totally separate product from any medical scheme.
If you are not fully covered by medical aids these are some of the risks YOU face:Not fully covered by medical aids. 2022 shortfalls paid by Gap Cover. 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 
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, so are funded from your savings. That can result in less money available for other medical needs and family limits being used on one member only!Exclusions
Anything from 3-months for everything, up to 12-months for specific conditions.Using a Broker
Brokers like ourselves offer valuable assistance in navigating the complexities of medical aid plans.
We will help you with the application process and answer any questions you may have and you don’t pay a cent for that service!
Remember, if you do go direct, you pay the same premium!
Send me your questions and concerns. I'll answer them for you.
083 655 2164
Medical aid pays healthcare costs.
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