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When should you upgrade your medical aid?

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You’re on a student plan. Or a family option you chose years ago. But now your needs have changed. The benefits no longer match your lifestyle. The costs feel harder to justify and you start asking if your current medical aid still fits.  That’s usually the first sign it’s time to reassess your cover.

In this blog, you’ll learn when it makes sense to upgrade, what rules apply, and how to compare options without pressure. The goal is to help you make the right choice for where you are now.

Understanding medical aid upgrades

Upgrading a medical aid doesn’t always mean switching providers.
In most cases, it means moving to a different option within the same medical scheme.

Medical schemes offer multiple options. These options differ in:

  • Benefits: What is covered, and how much.
  • Monthly contributions: What you pay.
  • Structure: Day-to-day benefits vs hospital cover, savings, limits.

All schemes follow rules set by the Council for Medical Aid (CMS). These rules create fairness across schemes. At the same time, schemes build options in different ways.

This distinction affects what you pay and what you’re covered for. In most cases, an upgrade means adjusting your option within the same scheme.

Common life changes that may trigger a review

Changes in your life often mean changes in your medical needs. Let’s look at some common triggers.

Changes in family structure:

  • Getting married or starting a family
  • Adding children or other dependants to your plan
  • Moving into a new phase of life
  • Your child becomes an adult dependant

These shifts require wider benefits, once you start planning for a family you’ll need maternity cover, and as your household grows your cover needs to keep up with their healthcare needs.

Changes in income or employment:

  • Moving from finishing your studies to now working full-time
  • Earning more than before. An average of 10% of your income should go to medical aid.

This can shift what’s affordable and what you expect from your cover. A starter option may no longer meet your needs.

Changes in healthcare usage

  • More frequent General Practitioner (GP) visits
  • Chronic medication or new diagnoses
  • Planning a procedure
  • Moving to a new town

If your current option limits how often you can claim, or what’s covered, it may be time to explore alternatives.

Are you allowed to upgrade your medical aid at any time?

Medical aid changes are regulated by the CMS. Generally, most schemes allow option changes once a year, during the medical aid review period (usually towards the end of the year).

However, certain life events may allow changes outside that window. This depends on your scheme’s rules. For example:

  • Getting married
  • Having a baby
  • Changing jobs

Always check with your scheme to see what’s allowed. Remember, scheme rules apply, and changes may be possible, but it’s not guaranteed. You will need a letter of motivation to switch plans outside of the benefit review period.

Signs your current option may no longer suit you

It’s not always obvious that your plan no longer fits. Here are a few signs it may be time to review your benefits:

  • You’re paying for benefits you don’t use
  • You often reach your benefit limits
  • You’ve had a major life change since joining
  • Your healthcare needs have increased

If these points feel familiar, reviewing options based on your current life situation helps.

Why comparing options is a smart first step

Upgrading is not the same as switching. Just looking at other options can give you clarity, without any commitment.

Here’s why comparing options helps:

  • You see benefits and costs side by side
  • You can assess which benefits matter most to you
  • You avoid overpaying for cover you don’t use

If you’re unsure if your current option still fits your needs, it may help to view your options based on your personal details.

How Medicalaid.co.za helps you review your options

Medicalaid.co.za offers a free, easy-to-use tool to compare medical aid options.
Here’s how it works:

  • Based on your age, income and family size
  • Shows real monthly contribution amounts
  • Explains benefits clearly, with hover-over tips
  • Designed to support informed choices, not to sell you a specific plan

This can help you understand which options suit your current life stage.

Use the Medicalaid.co.za comparison tool to view options that align with your current life stage.

Take a moment before you decide

You don’t need to upgrade your medical aid. But you should know if your current option still fits. Looking at your options is not a commitment. It’s a step toward clarity.

Here’s what matters:

  • Upgrading is your decision
  • Comparing options puts you in control
  • Knowing what you pay for helps you choose better

If you’ve started a new job, added a dependant, or your healthcare needs have changed, it’s time to review.

Use Medicalaid.co.za’s comparison tool to see which options match your life today.

5 Smart Medical Aid Tasks to Start the Year Right

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5 Smart medical aid tasks to do in January

Still recovering from festive spending? Your healthcare costs shouldn’t be the next surprise. For South Africans on medical aid, January is the most valuable time to lock in smart healthcare moves.

Think of it like a reset button for your healthcare. Get ahead now, and you’ll avoid unnecessary payments, claim rejections, and late-year panic.

Here are five simple but powerful tasks you can do this month to make sure your medical aid works for you.

1) Set up your preventive screenings early

Most medical aid schemes in South Africa cover essential preventive health screenings at no cost to you. These include:

  • Pap smears
  • Mammograms
  • Prostate exams
  • Cholesterol checks
  • Glucose tests

These medical aid benefits are often paid from your risk portion, not your savings, meaning they don’t reduce your available day-to-day funds.

January is the best time to book them. Not only are healthcare providers typically less busy, but it’s also easier to secure appointments that fit your schedule. Booking early also reduces the chance of forgetting about them altogether.

Some schemes, like Discovery’s Personal Health Fund,  reward members for staying proactive about their health. When you complete your annual health checks, you can unlock funds in your Personal Health Fund to use for everyday medical needs – including physio, mental health support or other out-of-hospital expenses. Many other medical schemes offer similar incentives for preventive care, encouraging members to act early rather than waiting until something goes wrong.

2) Check your savings and day-to-day medical aid benefits upfront

One of the easiest ways to lose money on medical aid is to misunderstand how your plan splits benefit between risk and savings.

Start by logging into your medical aid app or online portal. A healthcare broker can also help you with your needs analysis.

Take note of your:

  • Available medical savings balance
  • Annual day-to-day benefit limits
  • What services are covered under “risk” (typically includes screenings, chronic medication, immunisations)

For example, children’s vaccinations and dental checkups are usually paid from risk. But if you don’t claim them correctly or if the provider isn’t coded correctly, you could unintentionally use up your savings early in the year.

A few minutes now can help you avoid using your entire savings allocation before March.

3) Download your scheme’s app and activate digital authorisations

Medical aid apps are more than just balance checkers. They help you manage your medical aid benefits in real time.

If you haven’t already, download your scheme’s app and explore features like:

  • Digital pre-authorisations for hospital visits or specialist consultations
  • Claim submissions via photos or digital uploads
  • Provider search tools to find network-approved doctors or hospitals
  • Real-time benefit tracking

This isn’t just about convenience. If you can submit claims and authorisations quickly, you reduce the risk of delays or admin errors that lead to out-of-pocket payments. Plus, getting to grips with the app now means you’re ready when a real medical need arises later.

4) Make sure dependents still meet eligibility rules

Many members get caught out by dependent eligibility changes, especially after December, when children turn 21 or return to university.

Most medical aid schemes require updated documents for adult dependents. If your child is over 21 but still studying, you’ll likely need to submit a proof of registration or similar documentation. If that’s not done, they may be removed or reclassified as adult members, which often means:

  • Higher monthly premiums
  • Claims being rejected unexpectedly

Also, check whether new dependents (like a baby born in December) have been added and approved. Don’t assume the paperwork is automatic.

5) Review your DSPs for medication and planned procedures

Designated Service Providers (DSPs) are a critical part of managing your medical aid costs. Every scheme has a network of preferred:

  • Pharmacies
  • Hospitals
  • Medical specialists
  • Dentists
  • General Practitioners (GP)

If you use a provider outside your scheme’s Designated Service Provider (DSP) network, especially for chronic medication or planned procedures, you could face steep co-payments. Gap cover can help you with these types of co-payments

In January, go through your scheme’s updated 2026 DSP list. Make sure your:

  • GP is still in-network
  • Pharmacy is listed for chronic meds
  • Hospital choice for planned procedures is covered

If you need to switch providers, better to do it now before you need treatment.

For example, getting chronic medication from a pharmacy not on your network, can lead to an on average 30% co-payment (be sure to confirm with your broker and your scheme what sort of co-payment applies to your specific option. That’s a costly mistake that’s easy to avoid with a quick check.

Final Tip: One hour now can save you thousands later

Medical aid in South Africa is complex, but it’s not beyond your control. Spending just an hour in January reviewing your medical aid benefits, checking balances, and updating documents can save you thousands in avoidable expenses later in the year.

Think of it like setting up debit orders or doing your tax prep. It’s admin that pays off.

Already locked into your 2026 plan? No problem. You can still use MedicalAid.co.za to compare medical aid benefits, understand how your plan stacks up, and prepare better questions for your broker or scheme. It’s a smart way to stay informed, so your medical aid works for you all year.

What to do if you need emergency care over the festive season

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Each year, medical schemes review their benefits and contributions. These updates shape how much members pay, and what they receive in return, so taking a moment to understand what’s changing in 2026 can help you make smarter health cover decisions.

The festive season is known as the ‘period of celebration’ that takes place during December and some of January. For many South Africans it’s also the time to slow things down and spend quality time with family and friends, while enjoying a lekker braai.

Although there are much laughter and joy, it’s also a period where the rate of medical emergencies and accidents increase. Many of us don’t know what to do or who to call if an emergency arises. This blog provides you with important steps you can take if an emergency comes your way.

Common emergencies

Hospitals see more of these during December and January:

  • Drowning
  • Road accidents
  • Holiday decorating injuries
  • Food poisoning
  • Kitchen-related injuries
  • Slips and falls
  • Heatstroke

Being prepared matters. Acting correctly matters more.

Step 1: Stay calm and assess

Panic worsens emergencies, so it’s important to breathe. Check for danger. Do not move someone injured unless they are in immediate danger. Rather call emergency services for help. If you are bitten by a snake, try to take a photo of the snake so emergency services can identify if it is venomous and how to proceed.

Step 2: Call the right number

South Africa has multiple emergency lines:

  • 112 from any cell phone connects to all services
  • 10177 is the national ambulance number
  • Netcare 911: 082 911 (Private)
  • ER24: 084 124 (Private)

Private services work with most medical aids. Check your policy schedule to see what ambulance you can use.  Emergency services can guide you, dispatch ambulances, and manage hospital transfers.

Step 3: Pre-Authorisation

In the event of an emergency (ER Visit) the hospital will contact your medical aid for pre-authorisation. The medical aid will then send authorisation straight to the hospital. Remember you will also need to get pre-authorisation if you are admitted into hospital.

Quick tip: Ask if your medical aid has given authorisation for procedures before entering the Operating room, if not how much are they willing to pay. That is where gap cover will step in.

Step 4: Know what counts as a medical emergency

Emergencies include sudden life-threatening conditions that will cause loss of life, serious impairment of bodily function, serious and lasting damage to organs, limbs, or other body parts. These are known as Emergency Prescribed Minimum Benefit’s (PMBs).

Examples:

  • Uncontrolled bleeding
  • Breathing difficulties
  • Fit or epileptic seizure
  • Broken arms
  • Heart attack
  • A stroke

If your case does not meet these criteria, it may not qualify. Ask your provider for clarity.

Step 5: Go to a network hospital

Medical aids cover specific hospitals. Non-network hospitals may result in co-payments or full charges. In the event of an emergency and there is no network hospital within 40km then any hospital will be accepted.

Here are some tips on accessing your network:

  • Save your network hospitals on your phone
  • Check for hospitals near your holiday destination that are in your network
  • Be prepared to tell paramedics your scheme and plan type

Step 6: Keep your details ready

Time is critical. Keep these on hand:

  • Membership card or digital copy.
  • Plan type and number
  • Emergency contact
  • List of chronic conditions and current medication
  • ID copy

Store the details on your phone through your health ID and carry a hard copy in your car or bag.

Step 7: If you travel abroad

Most South African medical aids have limited cover international emergencies.

  • Ask your scheme about travel benefits and how much the maximum amount is
  • Consider travel insurance that covers medical emergencies

A small premium can prevent large bills.

Be prepared

The festive season should not leave you with debt or risk. Not all plans cover transport to hospitals, nor do they offer cover for all hospitals. It’s a good time to take a closer look at your benefits and potentially compare different medical aids in South Africa with MedicalAid.co.za. Ensure your plan covers emergencies, travel, and network hospitals.

Emergencies can happen at any time. During the festive season, services are stretched. Being informed is your protection. Save numbers. Know your cover. Know your nearest hospitals. Have your details ready. Help is only a call away. Will you take steps now to secure care for yourself and your family?

 

2026 Medical scheme benefit and premium update hub

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Each year, medical schemes review their benefits and contributions. These updates shape how much members pay, and what they receive in return, so taking a moment to understand what’s changing in 2026 can help you make smarter health cover decisions.

While increases still need regulatory approval, here’s a snapshot of confirmed updates and new benefits from South Africa’s leading medical schemes.

Bestmed

Bestmed has introduced an average benefit increase of 4.6% across all plans, along with several meaningful enhancements:

  • Preventative care: Faecal occult colon cancer screening is now available every 24 months for members over 40.
  • Surgical cover: Adenoidectomy for both adults and children has been added to the Rhythm 1 option, combined with tonsillectomy benefits.
  • Hearing devices: Cochlear implant and BAHA limits have been raised, up to R350,000 on Pace 4.
  • Breast reduction: Pace 3 and 4 now include a medically necessary breast reduction benefit, capped at R100,000.
  • Take-home medicine: Allowances for chronic and retail pharmacy take-home medication have been increased by at least 175%, now ranging from R450–R700.
  • Contraceptives: Female contraceptive benefits have been split into two clear limits: oral contraceptives (R2,092–R2,801) and IUDs (R3,295–R4,225).

Discovery Health

Discovery’s contribution increases will only apply from 1 April 2026, giving members a few extra months at current rates.

The Smart Saver range, launching 1 January 2026, brings a new combination of value and flexibility, including:

  • Up to 200% hospital cover on the Smart network.
  • A built-in Medical Savings Account.
  • A Personal Health Fund.
  • Unlimited Smart GP visits.
  • Dental, optical, and over-the-counter benefits.

Bonitas

Bonitas is focusing on younger members with its new BonCore plan, designed for individuals and couples aged 22–35. Benefits include:

  • Unlimited network hospital cover.
  • Unlimited virtual GP visits and 3 in-person consultations.
  • Cover for 28 chronic conditions.
  • A R1,000 Benefit Booster.
  • Preventative screenings.

The Primary Select plan has evolved into BonPrime, a savings plan with 16% allocated to savings, giving members more control over everyday costs.

Medihelp

Medihelp has two refreshed options stand out for 2026:

  • MedVital: Improved overall value across key benefits.
  • MedReach (previously MedElect): Now tailored for professionals seeking convenience and quality. Includes unlimited hospital cover, day-to-day benefits, and extended radiology, dental, and eye care coverage. The MedElect Student option has been discontinued.

Medshield

Medshield has a strong focus on screening and chronic care improvements this year:

  • AI Optical Diabetic Screening across all options except MediPhila and MediCurve.
  • Reduced chronic medicine co-payments on most plans.
  • Annual mammograms for women 30+ (previously every two years).
  • Dis-Chem has been added as a Designated Service Provider (DSP) for chronic medication.

Momentum Health

Momentum has introduced several preventive and accessibility upgrades:

  • FIT (Faecal Immunochemical Test): Now available annually for members aged 45–80 on all options except Ingwe.
  • Ingwe income brackets increased by 4.5% to make coverage more accessible.
  • Student/child principal rate: R645 per month.
  • Maternity benefit: Online antenatal and postnatal classes now hosted by ParentSense.
  • Dental cover: Preventative benefit raised to R500 per beneficiary.
  • Average co-payment increases of 4%.

Fedhealth

Fedhealth continues to expand coverage for women’s and mental health, as well as preventative care for seniors:

  • FlexiFED 1: Expanded maternity benefits, including more scans, consultations, and antenatal classes.
  • Mental health: Depression medication now covered even on entry-level plans.
  • Emergency contraception is now covered across all options.
  • Senior care: Pneumococcal vaccine added for members 65+.
  • Oncology: 25% higher brachytherapy limits on FlexiFED 4.
  • Day-to-Day Plus (D2D+): Rewards members who complete a health risk assessment and join Sanlam Health Rewards, unlocking up to R4,500 for additional day-to-day cover.

Compare your cover for 2026

Our updated comparison tool on MedicalAid.co.za now reflects 2026 benefits and contributions across all major schemes. It’s designed to help you see what’s changing, and decide whether your current plan still meets your needs.

Start the new year with confidence. Compare your cover and see exactly what you’ll be getting in 2026.

 

Making sense of your medical aid review period

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Just like every other year, in 2026, medical aid members all over South Africa will receive an updated set of benefits. Nearly all of these packs contain small, intricate changes that affect both your health and your wallet. Their fine print might be difficult to navigate, but here is some good news; understanding your review period for your medical aid does not have to be difficult. With the correct information, instead of making it stressful, this review period can be used to ensure that you are still receiving the best value for your money.

Why the review period matters

Think of the review period as your annual financial health check. It’s the moment when your medical aid scheme lays out what’s changing for the year ahead. Some changes will have little impact, while others could affect your household budget or even the doctor, you’re able to see.

Premium increases

The first thing most people notice is the higher monthly premium – a rise that’s almost inevitable, irrespective of any pay increase for the main member on the horizon.

Take this example: R200 a month may feel small, but over a year that’s R2,400. The real question is – does this extra cost add value to your future, or just drain your budget?

Benefit adjustments

Not all changes are bad news. Sometimes benefits improve, like more GP visits or higher allowances for specialist scans. Conversely, sometimes cover shrinks. Because of this, you’ll lose cover sooner and tiny changes end up accumulating. This is why you need to ensure that your plan suits your lifestyle and daily activities.

Provider network changes

This is one area where people often get caught off guard. You could find that your chosen clinic or MSP hospital is no longer in your plan’s network. When this happens, you might need to pay additional charges or change providers. Being informed of this enables you to prioritise what matters to you more, either continuing with your doctor or minimising expenses.

Out-of-pocket increases

Additional co-payments, new exclusions, or increased deductibles are all examples of concealed charges that can accumulate quietly over time. The problem is that you typically become aware of them during an emergency, when you do not expect to receive an additional bill. Fine-tuning your policy now can prevent those unpleasant surprises in the future.

Value-adds

Medical aid schemes love to talk about their “extras”: wellness apps, rewards programmes, or free preventative screenings. Some of these are genuinely useful, especially if they help you stay healthier for longer. Others might simply inflate your premiums without offering much day-to-day benefit. The key is to ask: Will I really use this?

 Time to reassess

Your 2026 benefit pack isn’t just paperwork: it’s a signal to pause and check if your medical aid plan still matches your lifestyle, health needs, and budget.

Don’t just accept the changes in your 2026 benefit pack. Compare your plan today with MedicalAid.co.za and find the option that truly fits your health and budget needs.

 

What the medical aid review period means for you (and why it starts before November)

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Every year around this time, something big happens in the world of medical aid, and it’s not just in November.

If you currently hold medical cover under an open medical aid scheme or are thinking of subscribing to one, the time between September and December is your months of opportunity. This is when medical scheme administrators begin updating existing schemes upwards in premiums, tweaking benefits, changing provider networks, and changing cover limits, all meant to be effective from the following January.

The knowledge of the annual review schedule stands to benefit your decision-making when determining health cover for 2026. Here follows some information for you to know.

What is the medical aid review period (and when does it start)?

The medical aid review period generally runs from late September through to December, although exact dates vary between schemes. Most of the major schemes begin releasing information in late September or early October, first to brokers and then to the public.

During this time, you’ll start seeing:

  • Premium (monthly contribution) changes
  • Updated benefit limits
  • Network provider adjustments
  • Revised co-payments or exclusions
  • New wellness tools or added-value services

While many refer to it as the “November review period,” the process typically kicks off from September, with more schemes revealing their updates as the weeks progress.

Why do these changes matter?

Your medical aid plan is not static and neither are your healthcare needs. Schemes revise their options annually to:

  • Keep pace with medical inflation and provider fee increases
  • Align with updated industry regulations
  • Adjust for changes in member claims and utilisation patterns
  • Introduce new digital tools or services for better member support

Staying informed about these updates is essential. A plan that served you well this year might not suit your needs or budget in 2026.

What to look out for during review season

When your scheme’s updates become available, pay close attention to:

  • Premium increases: What’s your new monthly cost?
  • Benefit adjustments: Are limits going up or down?
  • Provider network changes: Will your current doctor or hospital still be covered?
  • Out-of-pocket increases: Are there new co-payments or exclusions?
  • Value-adds: Are there any new wellness tools, apps or rewards?

Doing a medical aid comparison helps you weigh up your current plan against what’s newly available across different schemes and options, without necessarily switching funds.

Should you switch funds or just change options?

In most cases, switching to a different option within your current fund is the safer, easier route, especially if your needs have changed. Switching to a different scheme entirely can trigger new waiting periods or exclusions for certain conditions.

Unless there is a compelling reason, it’s usually better to stay within your existing medical aid and look at more suitable options under that umbrella.

How MedicalAid.co.za can help

With dozens of schemes and hundreds of options available in South Africa, comparing medical aids can quickly become overwhelming. That’s where MedicalAid.co.za comes in.

We track benefit updates and provide easy-to-understand comparisons, so you can see what fits your needs best, all in one place. Just note: not all premiums and benefits are available at once. Our updates are added as schemes release them, so check back often or speak to one of our consultants for real-time advice.

How to Prepare for the Review Period

Here are 4 simple steps:

  1. Review your current plan: Know what you are paying for, and which benefits you primarily use.
  2. Assess your healthcare needs: What has changed this year? Are there new diagnoses, dependants, or budget changes?
  3. Stay informed: Watch for communication from your scheme and follow any pertinent updates posted on MedicalAid.co.za.
  4. Get expert guidance: Consult a specialist if you need clarification. An informed decision today saves frustration (and bills) later.

In conclusion

Updates aside, whether that will happen in September or October, being proactive is what truly matters. This review period presents the perfect opportunity to reassess, realign, and ensure that your medical aid covers your needs. In view of this, with such foresight and by utilising the right tools, you should be able to step into 2026 with a plan that fits just perfectly.

 

The Power of Prevention: How Women Can Take Full Advantage of Their Preventative Care Benefits

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When it comes to women’s health, prevention is much more than peace of mind. It is a proactive measure to live well and stay well. Too often the benefits of preventive care are overlooked simply because we do not know that they exist.

But did you know that depending on your South African medical aid, you could have free or subsidised screenings, contraceptives and even maternity wellness services?

So how does preventative healthcare actually benefit you and how can you ensure that you are not missing out on benefits that your medical aid already pays for?

What preventative care is included in many medical aid plans

Preventative care benefits vary from plan to plan, but many South African medical aids include a core of free or subsidised services, either as part of Prescribed Minimum Benefits (PMBs) or specific scheme benefits.

These often include:

  • Annual PAP smears and mammograms (especially for women 40+)
  • HIV, cholesterol, and blood sugar screenings
  • Contraceptive cover — such as oral contraceptives, injectables, or IUDs
  • Childhood immunisations
  • Antenatal and postnatal care
  • Wellness screenings through pharmacies or scheme partners

While the exact details depend on your plan, most offer these preventative care services either from your risk benefit (not affecting your day-to-day savings) or as added value services. That means they often cost you nothing extra, you just need to use them.

Why using preventative benefits saves you more in the long run

These are carried out to help in the prevention of avoidable complications, which could be debilitating and costly. A routine PAP smear could catch the early signs of cervical cancer, and yearly breast exams may be able to detect abnormalities before they require invasive treatment. Likewise, checking blood pressure or glucose regularly is the best way to prevent future and far more severe complications such as stroke or diabetes.

By using these benefits early and consistently, you reduce your risk of:

  • Unexpected hospitalisations
  • Costly treatments down the line
  • Co-payments for avoidable chronic conditions

In other words, putting your health first today means fewer financial and emotional concerns tomorrow. It’s not merely about staying well; it’s about staying financially protected.

Maternity and contraception: What’s often included (and what’s not)

Preventative care becomes more pertinent if planning to have a baby or already expecting. Numerous medical funds offer separate maternity and contraceptive benefits designed to assist and accommodate you in every phase of your journey.

These may include:

  • Antenatal consultations (up to 6–12 visits)
  • Ultrasounds and blood tests
  • Newborn screenings
  • Access to 24/7 baby advice lines (like Bonitas’ Babyline)
  • Lactation consultants or milestone check-ups
  • Monthly allowances for antenatal supplements (e.g., R195/month for vitamins)
  • Contraceptive benefits, including hormonal options, implants, or IUDs

However, not all plans are created equal. Some cover these from the hospital benefit only, while others include dedicated maternity programmes, even on entry-level hospital plans. Always check the fine print.

How to find out what your plan includes

Understanding your preventative healthcare benefits starts with knowing where to look. Here’s how to make sure you’re in the know:

  • Log in to your member portal to view your benefits and remaining limits
  • Download the scheme’s benefit guide or brochure
  • Check if services are paid from your savings or the risk pool
  • Confirm which provider networks are covered
  • Ask if pre-authorisation is required for screenings or maternity care

If in doubt, speak directly to your medical aid or a broker who can walk you through your cover. Being informed means being empowered, especially when it comes to your health.

Prevention is powerful, and often already paid for

Your medical aid isn’t just a safety net – it’s a gateway to smarter, healthier living.  Preventative care covers a wide range of benefits, including contraceptives, cancer screenings, and maternity support.  Every woman’s health journey is unique and ever-changing – make sure you’re making the most of the benefits designed specifically for you.

So, next time you procrastinate when booking that check-up, or when reminders keep ringing for your respective screening, remember that prevention is not an option but a right.

Compare schemes now with MedicalAid.co.za to find a plan that puts your health first. Let’s help you make the most of your preventative healthcare benefits, because your wellbeing is worth it.

 

Understanding chronic benefits: What every South African should know before choosing a medical aid

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When it comes to long-term health, knowledge about chronic benefits becomes indispensable, especially in South Africa where medical schemes and health insurances do not always provide equal protection. If you or your loved one has a chronic condition such as diabetes, asthma, hypertension, or mental health diagnosis, knowing your rights becomes a matter of proper treatment versus financial stress. This blog will explain what the Prescribed Minimum Benefits (PMBs) are, how the Chronic Disease List (CDL) affects medical aid and mental health cover, what you can expect from mental health care, and the major differences between medical aid and health insurance. What is Prescribed Minimum Benefits? Prescribed minimum benefits or PMBs, are a set of 271 conditions that are covered by all medical aids in South Africa regardless of the plan you are on. These are the minimum benefits your medical aid must pay for by law. PMBs are divided into three main categories:
  • 271 Diagnosis and Treatment Pairs (DTPs): These are 271 conditions that have a specific medical diagnosis, each paired with a standardised treatment plan. Medical aid schemes are required to pay for the treatment of these conditions.
  • 26 Chronic Disease List (CDL) Conditions: These include 26 long-term, manageable illnesses such as Diabetes, HIV, and Bipolar Mood Disorder, etc. Medical aids are required to provide diagnosis, treatment, and ongoing care for these conditions.
  • Emergency PMB: These cover life-threatening medical situations where immediate treatment is needed to prevent serious harm or death. Medical schemes are obligated to cover the cost of emergency treatment. If you use a non-network hospital, you may be subject to co-payments unless there is no network hospital within 40 kilometres of your location.
What chronic conditions are protected under prescribed minimum benefits? PMBs are the basic set of services the open medical schemes must legally cover for all their members, irrespective of contribution level or plan type. The PMB list includes 271 PMB conditions and an additional 26 conditions which are classified as chronic diseases. Examples of these are epilepsy, diabetes, asthma, hypertension, bipolar mood disorder, and schizophrenia. Schemes must cover these at the PMB level of care, but members should know that using non-formulary medicines or non-designated providers may result in co-payments. How the chronic disease list determines what your scheme must pay for The Chronic Disease List (CDL) is an official list of 26 chronic conditions. It includes a wide range of illnesses, from cardiovascular disease to HIV, and even certain mental health conditions. This list is more than just a reference: it’s a legal standard. Your medical aid scheme is obligated to provide treatment and medication for these conditions, typically guided by treatment algorithms set by the Council for Medical Schemes (CMS). Members can get treated for each of these conditions, but it is only the 26 chronic conditions that will be covered as “Prescribed Minimum Benefits” by the medical plan. Important: While schemes must cover the conditions on the CDL, the type and brand of medication, or the specialists you can visit, may be subject to scheme rules. Always read the fine print. How mental health is treated under chronic benefits Only certain mental health conditions, such as bipolar mood disorder and schizophrenia, are explicitly listed under the Chronic Disease List (CDL). Depression and anxiety are not included in the official CDL list of 26 chronic conditions. It’s important to understand that Prescribed Minimum Benefits are defined by conditions that threaten your life or quality of life, so not all mental health treatments automatically qualify. If your medical scheme provides cover for depression or anxiety outside of CDLs, this is usually part of their Non-Chronic Disease List (Non-CDL) benefits, which often come with specified annual limits. Depression and anxiety are not on the CDL list, so they’re not automatically covered as PMBs in the same ongoing, outpatient manner. However, they can still be treated as PMBs in specific circumstances, particularly if they present as:
  • A mental health emergency (e.g. psychotic episodes, or severe breakdowns).
  • A comorbidity of another PMB condition.
  • Conditions resulting in involuntary admission or hospitalisation under the Mental Health Care Act.
Because CDLs are a fixed legal standard, schemes cannot offer extra CDLs but may provide additional benefits beyond those minimum requirements. Clear understanding of these distinctions ensures you know exactly what your plan covers. MedicalAid.co.za makes this process easy by allowing you to select if you want to include chronic medication in your comparison or not. When choosing medical aid mental health cover, it’s important to find out whether your scheme includes therapy and psychiatric consultations, and how these are covered. Many schemes don’t just limit the number of sessions; instead, they set a rand value limit. For example, a plan might cover “2 specialist visits or R4,500 per year,” whichever comes first. Some may allow a certain number of visits but cap the total amount they’ll pay, such as covering 2 visits up to R1,500, with any costs beyond that being your responsibility. This is often because specialist consultations can be quite expensive, and medical aids aim to manage those costs carefully. Many members aren’t aware that specific ongoing mental health treatment can be claimed from your chronic benefits, so it’s important to ensure that your condition is registered to avoid out-of-pocket surprise expenses. Medical aid vs health insurance: What’s the difference when it comes to chronic care? It’s common to confuse medical aid and health insurance, but when it comes to chronic conditions, the difference matters. If you are managing a long-term illness, health insurance alone is not enough. It won’t provide the same guaranteed access to treatment as medical aid does. It is also important to note that medical insurance usually does offer cover for some chronic conditions, and as a result they do offer limited cover for chronic medication and for specialist visits. It varies according to the insurance plan. What the Council for Medical Schemes says about your rights to chronic care The Council for Medical Schemes (CMS) is the regulatory body that protects the rights of members of medical aids. They ensure all schemes follow the law and honour their obligations around chronic benefits. Final thoughts If you or someone in your family is living with a chronic condition, don’t leave your healthcare to chance. Whether it’s managing high blood pressure, mental health conditions, or diabetes, it’s critical to understand what your medical aid must legally provide. Medical schemes are bound by law to offer PMBs and cover for the 26 CDL conditions and 271 PMB conditions. But not all plans offer equal value, and health insurance might not give you the same protection. Before you renew or sign up for a new plan, read a recent post compare your options and make sure your scheme supports your long-term needs. Start with a MedicalAid.co.za quote today to find affordable medical aid quotes that include the chronic benefits you deserve. Get a Free Medical Aid Quote  

Understanding medical aid limits, sub-limits, and exclusions

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Terms such as “limits,” “sub-limits,” and “exclusions” arise in the context of medical aid plans and can make an already daunting decision much more confusing. Understanding medical aid is about more than just monthly contributions or benefits. It’s also about what is not covered and how much protection is left when the time really matters. This guide will explain what medical aid limits and sub-limits are, explain some common medical aid exclusions, and assist you in making more informed decisions using tools such like the free MedicalAid.co.za comparison platform. What are medical aid limits? Medical aid limits represent the maximum amount that your particular scheme will pay for a range of healthcare services each year. More commonly, this is referred to as the overall annual limit, which is the total amount of benefits you can claim in a year. For example, if your medical aid plan has an annual limit of R500,000, and the total amount of your claims adds up to this amount, any additional costs will need to be paid by you until the limit resets the next year. While some comprehensive plans may not apply overall limits, many capitation or entry-level plans do. Understanding these medical plan caps is critical to avoiding nasty surprises, especially during medical emergencies, planned medical procedures or when managing a chronic illness. Decoding sub-limits in medical aid Sub-limits are more specific than limits: they restrict how much your plan will pay for very specific procedures or treatments, regardless of where you are still within your overall annual limit. For instance a medical scheme may include sub-limits similar to these:
  • MRI and CT scans may have a sublimit of up to R10,000 per year.
  • Hearing aids or prosthetics might be capped at around R5,000.
  • Certain dental procedures may only be covered up to a fixed amount, regardless of the total cost.
These medical aid sub-limits can catch you off guard. You might assume you’re fully covered, only to find you owe thousands for a treatment that exceeded a sublimit you were not aware of. Common exclusions in medical aid plans Exclusions are treatments or procedures your plan won’t cover at all – no matter your overall limit or benefit tier. Typical medical aid exclusions include:
  • Cosmetic surgery (unless medically necessary)
  • Experimental or unproven treatments
  • Infertility treatments
  • Certain over-the-counter medications
  • Alternative therapies not recognised by the Scheme
Understanding medical aid exclusions is just as important as knowing your benefits. A treatment that isn’t covered means you pay 100% out of pocket. Impact of limits and sub-limits on your cover Limits and sub-limits don’t just restrict access, they also create out-of-pocket costs. If a procedure costs more than your sublimit allows, you must pay the difference. In some cases, this could mean tens of thousands of rands. This is where gap cover becomes essential. Gap cover is a separate policy designed to cover the shortfall between what your medical aid pays and what private specialists actually charge. It doesn’t replace your medical aid, it protects you from the financial “gaps” that limits and exclusions can create. Some plans also require co-payments, a set amount you must contribute towards a procedure. This often applies to high-cost treatments or when using providers outside your scheme’s designated service providers (DSPs). How to compare medical aid plans effectively Making sense of all this is no easy task, but the right tools make all the difference. If you’re doing a medical aid comparison in South Africa, be sure to:
  • Check both annual limits and individual sub-limits
  • Review the list of medical aid exclusions carefully
  • Understand co-payment requirements
  • Compare hospital plans vs comprehensive plans side by side
  • Assess whether you’ll need gap cover for peace of mind
The free comparison tool at MedicalAid.co.za helps you evaluate options clearly, whether you’re already on a plan or looking for a new one. Not on a medical aid yet? You can get a quote here. Conclusion Understanding medical aid is about more than just your monthly premium. It’s about knowing the fine print, medical aid limits, sub-limits, and exclusions, so you can protect yourself and your family from unexpected costs. Use smart tools, read the details, and when in doubt, speak to an advisor who can help you navigate the complexity.    

When should you compare your medical aid?

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In a country like South Africa, where access to quality healthcare can be the difference between security and stress, medical aid is more than a nice-to-have, it’s a necessity. But here’s the thing: just because you have medical aid doesn’t mean you have the right one. Too often, people sign up for a plan and stick with it year after year, even when their lives, and their health needs, have completely changed. The reality? The best time to compare medical aid plans in South Africa might be right now. Whether you’re considering a switch between major players like Bonitas and Discovery or simply trying to compare medical aid prices that fit your budget, timing is everything. So, when should you compare your medical aid? Let’s dive in.
  1. Annual review time: Your once-a-year opportunity
Think of it as the Black Friday of medical aid. Most South African medical schemes open their review windows toward the end of the year. This is your golden opportunity to assess your current plan, benefits, exclusions, premiums, and decide if it’s still working for you. This is also when most updates to plan structures happen. Waiting until January might mean locking yourself into another year of mismatched cover or unnecessary expenses. Tip: Use a smart online comparison tool like MedicalAid.co.za to compare medical aid plans for 2025 quickly and easily.
  1. Life changes that impact your medical needs
Life doesn’t stand still, and neither should your cover. Major life milestones often change what you need from a medical aid plan. Here are a few examples:
  • Getting married or divorced
  • Having a baby
  • Entering a new age bracket
  • Developing a chronic condition
Each of these shifts could mean your current plan no longer fits, or that you’re overpaying for benefits you don’t need. When you compare Bonitas and Discovery medical aid or explore other options during these moments, you’re not just reacting, you’re planning smartly for what’s ahead.
  1. Financial changes: Income in, budget out?
Whether it’s a raise, a retrenchment, or just a tighter monthly budget, financial shifts often call for a fresh look at your healthcare cover. Medical aid isn’t cheap. But that doesn’t mean you have to sacrifice quality care for affordability. It just means you should compare cheap medical aid prices in South Africa to find the right balance. But also remember, cheap is not always better and you what you save on premiums could end up costing more on day-to-day out of pocket and co-payments. So, comparing before changing plans is a good idea. Think of it as financial self-care.
  1. When your benefits just aren’t cutting it
Here’s a red flag checklist:
  • You’re paying out-of-pocket more than expected
  • You’ve hit your limits halfway through the year
  • You need cover for specific treatments, and don’t have it
If you’re nodding along, your medical aid plan may be doing the bare minimum for maximum cost. That’s when it’s time to compare medical aid hospital plans in South Africa and find better options for the same monthly contribution. Because peace of mind should not come with small print stress.
  1. If you haven’t compared in over a year
Let’s be honest, how often do you really read those benefit updates your scheme emails each year? Medical aid schemes update their premiums, networks, and benefit structures every year. If you haven’t checked in 12 months or more, your plan might no longer offer the same value it once did. Or it’s offering new value that you don’t need, but inevitably are paying for. A quick comparison could reveal better benefits at the same, or lower, price. Bottom line: Your health (and wallet) deserves better The key takeaway? You don’t have to wait for a crisis, or the end of the year, to take control of your cover. Whether it’s a lifestyle change, a financial shakeup, or just a gut feeling that your benefits aren’t up to scratch, knowing when to compare medical aid plans in South Africa is one of the smartest preventative care moves you can make.