Tag: changing medical ad options

Does your current medical aid still fit your needs?

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If you have caught yourself asking, “does my medical aid cover my needs?”, you’re not alone. Many South Africans stay on the same medical aid plan for years, even as their life, health needs, and monthly income and expenses change.

With medical aid costs escalating, it could be worth investigating whether your cover still fits your needs. For all you know, you could be saving thousands of rands in the long run.

That’s why it’s important to have a self-check system to help you spot when your current option may no longer be the right fit.

If a few of the signs below feel familiar, you can view options on Medicalaid.co.za to compare monthly costs and benefits based on your household details, before opting for “the cheapest” one.

Why “fit” changes over time

The medical aid plan that worked when you started your first job might not work as well now. Life doesn’t stand still, and neither should your medical cover. A new marriage, a growing family, a salary increase, or a health diagnosis can all shift what you need from your plan.

It also helps to remember that medical scheme benefits and rules differ by scheme and by option. Even when two options sound similar, they may handle day to day limits, hospital networks, and co-payments differently.

The goal is not simply “the cheapest”. It’s the best match between what you pay in monthly contributions and the benefits you’re most likely to use.

7 signs your current option may not match your needs

1.     Your monthly contribution has become difficult to manage

If contributions are rising faster than your income, it may be time to reassess what you genuinely use versus what you’re paying for.

 2.     You’re paying out of pocket more than expected

Many out-of-hospital benefits have limits and rules. Depending on the option, co-payments can apply, and some services may be subject to benefit caps.

3.     Your family structure changed

Getting married, adding dependents, or planning for a baby can all change what kind of medical aid suits you best. So can your children’s needs, like dental check-ups or getting spectacles.

4.     You are using the hospital more or planning a procedure

If hospital admissions, specialist consultations, or planned procedures are becoming more likely, review:

  • hospital benefits,
  • pre-authorisation rules,
  • network requirements,
  • and what can trigger co-payments.

5.     You have a new diagnosis or ongoing medicine needs

Prescribed Minimum Benefits (PMBs) are a regulated set of benefits that cover specific conditions, no matter which medical aid plan you choose, but schemes may apply processes and treatment protocols.

6.     Your option’s network rules do not match where you get care.

Some options are built around a network or Designated Service Provider (DSP) arrangement. Using providers outside that arrangement can affect what is paid.

7.     You have not reviewed your benefits in 12 months

An annual review helps you avoid “set and forget”. Your needs, budget, and the option’s rules may have changed.

If two or more signs apply, it may be time to view options and compare monthly costs and benefits based on your household needs.

What to review before you switch or upgrade

Benefit category match

Use a simple “what do I use?” lens:

  • Day-to-day benefits: General Practitioner (GP) visits, basic dentistry, basic optometry, acute medicine, and related limits.
  • Hospital benefits: admission rules, authorisation requirements, and network arrangements.
  • Chronic medicine arrangements: how ongoing medicine is managed, and what processes apply.
  • Family needs: dependants, maternity related benefits (if relevant), and children’s routine care.

A quick way to ground this is to look back at the last three to six months of claims and receipts, then compare that against the option’s stated benefits and rules.

Example scenario (young professional)

You start your first job and mostly need GP visits and the odd dental check-up. A year later, you begin seeing a specialist and your out-of-pocket costs increase. That’s a clear sign it’s time to review your plan and check if your day-to-day benefits and specialist cover still meet your needs.

Example scenario (family)

You add a spouse and child, and suddenly there are more dental visits, eye tests, and trips to the pharmacy. When your family grows, it’s a good time to review your cover by checking dependant rules, day-to-day limits, and hospital network requirements to make sure your plan still fits.

Rules that can affect access to benefits

Two rule areas often surprise people:

  • Waiting periods: these can apply for new members depending on circumstances, and full disclosure matters.
  • Late joiner penalties: these may apply in certain cases under the Regulation 13 of the Medical Scheme Act. (often linked to joining after the age of 35 and not belonging to a scheme for a long period).

Because these topics can be technical, keep it high level at first and confirm details in the official scheme rules before acting.

Before you switch, compare monthly costs and benefits side by side so you can see how options differ for your household. View options on Medicalaid.co.za.

The simplest way to sanity-check your fit: compare your options

If you’re unsure what to do next, start with a clean comparison. Medicalaid.co.za is a decision support tool that lets you enter your age, income, and family structure to see real monthly costs and plain language benefit explanations.

Comparison supports informed decision making. It doesn’t guarantee savings, and you should always confirm final details in official scheme rules.

Ready for a clearer view? View options on Medicalaid.co.za to compare monthly costs and benefits based on your household needs.

When can you upgrade or change your medical aid plan, and how to decide

When can you upgrade or change your medical aid plan, and how to decide

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Reviewed by Lincoln O’Ehley, General Manager at MedQuote

Published by MedicalAid.co.za | Last updated: 12 October 2026

MedicalAid.co.za is a free comparison service. It is not a medical scheme and does not provide cover.

THE SHORT ANSWER

Review season is when you decide whether to upgrade, downgrade, change scheme or stay. Most schemes open their option-change window from around October and keep it open to the end of December, though some close earlier. The change takes effect on 1 January, unless otherwise specified. You can apply to join a different scheme at any time of year.

That is the short answer. The longer one matters, because schemes publish next year’s changes at different points during the benefit review season, so the gap between having the information and having to decide can be short. This page sets out the dates, what changes, and five checks to do before you make your decision.

When you can change your plan: the annual option-change window

DEFINITION

Option-change window: the period each year when a scheme lets existing members move to a different option on the same scheme. Changing to a different scheme is a separate process and is not limited to this window.

Medical schemes operate under the Medical Schemes Act 131 of 1998 and are regulated by the Council for Medical Schemes. The Act sets no national date for changing options. Each scheme submits its proposed premium increases and benefit changes to the Council, but schemes can decide when to open their option-change window.

If you don’t want to stay on your option, then there is one of two changes you’re able to make:

  • Changing option on your current scheme. During the annual window, or mid-year on a motivated application.
  • Changing to a different scheme. You can apply at any time of year, the acceptance of which is subject to underwriting and waiting periods. Most do it at review season.

The annual cycle is consistent across schemes even though the dates are not:

  1. The scheme submits next year’s contributions and benefits to the Council for review.
  2. The scheme notifies members of what is changing on each option, usually between September and November.
  3. The window opens, and members may move between options or to another scheme.
  4. The window closes. Changes usually take effect on 1 January, though a scheme can defer an increase.

Why the window is shorter than it looks

The window in the table below can run for weeks, but the useful part of it is shorter. Schemes publish next year’s contributions and benefit changes at different points, generally between September and November, so the time you have to compare is often shorter than the window in which you can change.

A scheme cannot ask members to choose until next year’s contributions and benefits have cleared the Council’s annual review. It then has to load the new option, move registrations, and let employers adjust payroll before 1 January.

Two dates are worth asking your scheme for: the closing date of the window, and any earlier deadline for submitting a change so it can be processed before 1 January.

Option-change windows by scheme

Listed alphabetically. The order is not a ranking. These are among the larger open schemes, not a complete list of those in South Africa.

Scheme (alphabetical) Option-change window for 2027 Effective date
Bestmed Medical Scheme 1 Oct – 31 Dec 2026 1 Jan 2027
Bonitas Medical Fund 20 Oct – 30 Nov 2026 1 Jan 2027
Discovery Health Medical Scheme 29 Oct – 30 Nov 2026 1 Jan 2027
Fedhealth Medical Scheme 1 Oct – 30 Nov 2026 1 Jan 2027
KeyHealth Medical Scheme 12 Oct – 15 Dec 2026 1 Jan 2027
Medihelp Medical Scheme 1 Oct – 30 Nov 2026 1 Jan 2027
Medshield Medical Scheme 20 Oct – 15 Dec 2026 1 Jan 2027
Momentum Medical Scheme 20 Oct – 30 Nov 2026 1 Jan 2027

Maintained by MedicalAid.co.za. Dates accurate as of 9 October 2026. Schemes marked as not yet announced will be added as they announce. Dates change annually and schemes sometimes extend a window at short notice. Contribution increases and benefit changes do not always take effect on the same date.

Can you change your plan during the year?

Yes, but acceptance of your application isn’t guaranteed. A mid-year option change needs a motivated application your scheme approves, on grounds set out in its rules. Those rules differ by scheme, including whether a downgrade is treated differently from an upgrade.

Reasons commonly considered by the scheme:

  • Moving to another province where you will need a different network list for designated service providers. For example, if you were on a plan that focused on a coastal network, but you move inland then you need a plan that has a network focused on inland providers.
  • A life-changing event, such as pregnancy, marriage or a new medical diagnosis (e.g., cancer).
  • A change in employment, where you join or leave an employer group with its own options.

Where a scheme discontinues or restructures your option it will tell you and offer a replacement, under the rules it registers with the Council. If you do not respond you are usually moved onto it automatically.

“Members are often moved onto a replacement option without realising it, because the notice reads like administration rather than a decision, so ensure that you understand how your current plan may be impacted for the following benefit year,” says Lincoln O’Ehley, General Manager at MedQuote.

Changing to a different scheme is less restricted. You can apply at any time of year, approval of which is subject to underwriting and waiting periods, covered on MedXpert’s guide to waiting periods and underwriting.

What actually changes at review season

Five things are reviewed annually and your contribution is only one of them.

  1. Your contribution. Increases are announced and are subject to approval by the Council for Medical Schemes.
  2. The benefit structure of your option. Limits, sub-limits, savings allocations, and co-payment rules can all change, so assess whether the new benefits offer sufficient value for money.
  3. Which options exist. Schemes close, merge and restructure options. An example of the latter would be changing an option from a traditional structure to a savings-focused structure.
  4. The provider network. Provider arrangements are renegotiated annually, so your current provider might not be on the list for the next year.
  5. The medicine formulary. The list of medicines covered in full is reviewed annually. If your current medicine isn’t approved, then look at whether a generic will be covered. If neither is covered by the plan, then you will need to cover those costs out-of-pocket.

The decision: five checks to run against your current plan

The big question is whether your plan’s changes will still meet your needs. The first four checks need only your scheme’s information.

Check 1. Has your usage changed since you chose this option?

Pull your last twelve months of claims from your scheme’s app and see where the money went. If day-to-day claims have grown while hospital claims stayed at zero, or the reverse, you might benefit from a different type of plan that has a greater focus on day-to-day benefits.

Check 2. Has your option’s benefit structure changed for the coming year?

Read the benefit change communication, not only the contribution letter. Having a good idea of how your plan has changed will help you understand if your new benefits fit your needs. Was there a reduced sub-limit, or an added co-payment, or a change in Savings allocation? How was my chronic care programme changed and what can I expect from the network list? These are all checks worth making.

Check 3. Are your providers still in network?

Check your GP, specialist, hospital and pharmacy against next year’s network list. If your GP has been removed from the network and you continue to consult with them then you’ll need to shoulder the additional costs.

Check 4. Is your chronic medicine still on the formulary?

If you or a dependant is registered for chronic medication, check each item against the formulary for the option you will be on in January.

Check 5. Would the same contribution buy a different type of plan?

Look at your contribution and compare it against other plans with a similar contribution, be it with your scheme or with another scheme, and look at what benefits that plan has vs what your plan has. Are you able to extract the same value for money on a Savings option vs a Traditional one? The point is not a premium, but the value for money.

Upgrade, downgrade, change scheme or stay

No single answer fits everyone.

What the checks showed What that points to
Your claims exceed your option’s limits, or you pay out of pocket for cover you expected to have Look at whether a different plan type covers what you claim for and use that as a guide to upgrade or move to another option.
You claim well under your limits and your savings allocation carries over unused each year Look at what you pay for and do not use. You might benefit from a lower premium option that has a different benefit structure if your needs will still be met.
Your providers or your medicines are no longer covered as they were Check whether another option, or another scheme, keeps them. If you know that the changing network won’t suit you then use the benefit review window to move to a different plan. If you move midyear to a new province that doesn’t fit into your current network, then you can request an option change outside of the window and your scheme will review the request.
Your claims match your option, your providers are on the network lists, and your medicines are on the formulary If these points hold, staying on your current option is a reasonable outcome. If the new contribution is outside your budget, consider which benefits you could give up by moving to a lower option.

Your review-season checklist

Six steps, in order, before your scheme’s window closes.

  1. Find your scheme’s closing date and ensure your application is submitted well before then.
  2. Work through the five checks above with a specific focus on your claim patterns and your needs.
  3. Add up what you paid out of pocket this year.
  4. Compare against the other options on your scheme at a similar contribution.
  5. Compare across other open schemes at a similar contribution.
  6. Submit your change in writing before the closing date and keep the confirmation.

If you decide to move, and by when

Changing options on your current scheme is the simpler route. Complete the form before the closing date, make a note of your query number and keep an eye on your inbox for your new membership certificate.

If you register chronic medication, you need to ensure that your condition and medicine are authorised for the new year. This includes ensuring that your network pharmacy has the most recent script. If your network pharmacy needs to deliver your medication each month then confirm the delivery address and if any co-payments will be applicable for the new year.

Changing scheme involves underwriting and follows a unique process, so start early if it’s something you want to do. You can compare open medical schemes side by side on MedicalAid.co.za, free of charge, and request a call back.

Frequently asked questions

Can I change my medical aid during the year, or only in January?

Changing option outside the annual window needs a motivated application the scheme approves, on grounds set out in its rules, such as a life-changing event like having a baby or moving to a different province. Changing scheme isn’t restricted: you can apply at any time of year, but admissions will be subject to underwriting and waiting periods.

When does medical aid review season start in South Africa?

Schemes usually publish contribution and benefit changes between September and November, and option-change windows generally run from around October to the end of December, though some schemes close earlier, for changes effective 1 January. Exact dates differ by scheme, but the Medical Schemes Act requires that there is a period of at least 30 days before any changes are put in place.

If I change my option, do I have to serve waiting periods again?

If you move options within the same scheme, your waiting periods will not start over. You might carry over your waiting period if it hasn’t ended by the time you move options, but you won’t serve the same waiting period again. Waiting periods and underwriting are complex and are governed by the Act and the scheme’s rules. See MedXpert’s guide to waiting periods and underwriting.

My contribution is going up. What should I check if I want to stay on the same plan?

Check whether the increase comes with a change in benefit structure, or whether another option allocates the same money differently and in a way that could meet your needs better. Confirm that your service providers and medicines are still covered by your option’s network and formularies. Look for co-payments and consider how it will affect your pocket, as well as if gap cover is something worth taking out.