Top 10 Facts About South African Medical Aid Schemes

Medical Aid Schemes form an important part of health care funding in South Africa.

It is in the interests of you and your family’s health and well-being to join the best one you can find, remaining a member for as long as possible in order to keep the premiums affordable. The later in life that you join a medical aid, the more expensive the premium.

Here are the 10 most important facts about medical aid schemes that you should keep in mind when looking for the medical aid scheme that suits you.

  1. There are 93 medical aid schemes in South Africa. Most of these are restricted, meaning that only employees of certain companies can join them, such as the AECI medical scheme for employees of AECI. The other kind are so-called open schemes that anyone may join, such as the Discovery Health Medical Scheme and the Sizwe Medical Fund.
  2. Open medical aid schemes are open to anyone while restricted medical schemes are exclusively for the employees or members of a company or institution and their families. Open medical aid schemes are obliged to accept anyone as a member. They give a the prospective member a tailored quote before the person agrees to join and the schemes are obliged to accept your dependents as members too.
  3. You can join a medical scheme via a broker or directly.
  4. It is illegal to belong to more than one medical scheme at a time.
  5. The body that oversees the medical aid industry is the Council for Medical Schemes (CMS).
  6. The legislation governing the medical aid schemes is the Medical Schemes Act of 1998, which came into operation on 1 February 1999. The regulations relating to the Act came into effect in the following two years.
  7. The Medical Schemes Act requires every medical scheme to provide Prescribed Minimum Benefits (PMBs), which number some 300 conditions, including about 27 chronic conditions. Medical schemes are obliged to pay all the costs of these including diagnosis, treatment, hospitalisation and medication.Top 10 Facts About Medical Aids in South Africa
  8. There are certain steps that must be taken before you can draw benefits. It is important to understand these. For instance, you may need pre-authorisation for certain treatments and hospital admissions, or you may be obliged to use a Designated Service Provider (DSP), meaning a certain doctor or specialist or hospital in terms of the rules of your medical scheme. Every claim must include the correct codes, which are obtainable from the doctor, dentist or specialist concerned.
  9. A co-payment may result in certain case, meaning that the scheme member may have to make a financial contribution for diagnosis, treatment, consultation, hospitalisation or medication. It is important to adhere to the claims procedures of your schemes to minimise co-payments.
  10. The largest open medical aid scheme in South Africa is the Discovery Health Medical Scheme. Other major, open medical aid companies include Bestmed, Bonitas, Fedhealth, Keyhealth, Liberty, Momentum and Sizwe Medical Fund.