Important considerations when choosing a medical scheme

Before choosing a medical scheme, and an option within that medical scheme, you need to consider the following points:

Needs and financial analysis

When deciding to join a medical scheme, first ask yourself what you can afford to spend on the monthly premium per month. Then look at your and your family’s needs. What is it that you need from your medical scheme?

Membership and solvency ratio

It is very important to look at the scheme’s membership status and solvency ratio. Some schemes have a big member base, but their solvency ratio is far below the required 25%. This means the scheme is likely to have a bigger premium increase at the end of the year. Solvency ratios may drop annually, should a scheme have a bad claims experience that year.

Other schemes’ membership might be small, but the solvency ratio is high, which means enough funds are available and premium increases at the end of the year can be expected to be lower than the average in the market.


It is important to know who the administrator is and how efficient he is in offering assistance, client services and paying out claims.

There are lots of good products in the market, but when it comes to the administration thereof, many schemes fall short.

Ask your broker for assistance with this or visit the Council for Medical Schemes Website.

In-hospital benefits, exclusions and co-payments

Before deciding on which scheme you want to join, you have to look at the cover each one offers you. The most important question is, how are you covered in hospital?

Most schemes cover you at 100% of the National Reference Price List (NHRPL) tariff, better known as the normal medical scheme rate. Other options cover you at 120%, 150%, 200% or even 300%. This means it is ALWAYS vital to negotiate rates with the medical provider (anaesthetist, specialist, doctor, etc.) If you don’t do that, you will be liable for the difference in costs. The other option is to take out an additional product to cover that cost, like Gapcover.

Read the small print! Study your product brochure to make sure of what is excluded on your option. Some schemes will exclude joint replacements or neck and back operations, so it is VERY important to take note of exclusions. You will then know exactly what you are covered for and what not, so that you cannot be “caught with your pants down”.

It is also important to be aware of all co-payments. Many schemes have co-payments (i.e. covered from your pocket) on certain procedures, like gastroscopies, laparoscopies, removal of wisdom teeth, colonoscopies and joint replacements. The co-payments differ from scheme to scheme and also depend on whether the procedure is done in or out of hospital.

Out-of-hospital cover

Most options in the marketplace work with “savings”. These are the so-called New Generation options, where you are given a percentage of your monthly premium upfront for the year. This is available to you immediately, depending on the applicable waiting period.

These “savings” will be used for almost everything outside of hospitalisation and also for any co-payment you might have. Once the savings have been depleted for the year, you will have to pay for the out-of-hospital expenses out of your own pocket. Some products have built-in threshold levels, which can be to your advantage should your claims be high. These are usually the Comprehensive options.

You could also decide to join a Network/Capitation option, where you have to make use of a specific service provider like Care Cross, Primecure, Keycare etc. The advantage of these options is that you can make use of that network GP and dentist as many times as you like, as the consultations are unlimited.

Chronic medication

When it comes to chronic medication, first make sure it is covered on the option you want to join. Make 100% sure your condition is regarded as a chronic condition and then that the medication you use is also covered.

Most people join an option because it covers their condition, but when it comes to the medication, the scheme says it is not on their formulary and is not covered. They will then request you to use an alternative. If that is not possible, they will pay you the rand amount for the alternative and you will be liable for the difference in cost.

Oncology, dialysis and HIV

You also have to make sure how the scheme and option cover oncology, dialysis and HIV. Most schemes have specific benefit programmes for these conditions, which offer good cover, but it is important to make sure exactly what that cover is.