Medical Aid: Frequently Asked Questions
1. What is a medical aid scheme?
A medical aid scheme is a registered, not-for-profit fund regulated under the Medical Schemes Act that pools member contributions to pay for healthcare expenses.
2. How is medical aid different from health insurance?
Medical aid schemes must provide Prescribed Minimum Benefits (PMBs) and are community-rated. Health insurance provides defined benefits and is regulated under insurance legislation.
3. What are Prescribed Minimum Benefits (PMBs)?
PMBs are a set of legislated minimum benefits that all medical schemes must cover, regardless of plan type, provided treatment protocols are followed.
4. Is medical aid mandatory in South Africa?
No, but it is strongly recommended due to the high cost of private healthcare.
5. Can I use private hospitals with medical aid?
Yes, depending on your plan. Some plans offer full hospital access, while others are network-based.
6. What does medical aid typically cover?
Depending on the plan:
In-hospital treatment
Specialist consultations
Chronic medication
Day-to-day GP visits
Dentistry and optometry
Radiology and pathology
Oncology
Emergency medical services
7. What is the difference between hospital plans and comprehensive plans?
Hospital plans primarily cover in-hospital expenses. Comprehensive plans include both hospital cover and day-to-day benefits.
8. Are specialist fees fully covered?
Not always. Specialists may charge above scheme rates, which can result in shortfalls unless covered by a higher-tier plan or Gap Cover.
9. What are medical savings accounts (MSAs)?
Some plans allocate a portion of your contribution to a savings account used for day-to-day medical expenses.
10. What happens when my savings are depleted?
You will need to pay out of pocket unless your plan provides additional risk benefits.
11. Is chronic medication covered?
Yes, for approved chronic conditions registered under the scheme’s chronic programme and subject to formularies.
12. Is maternity covered?
Yes, subject to waiting periods and scheme rules. PMB conditions related to maternity are covered.
13. Are dental and optometry covered?
Coverage depends on the plan. Some include benefits from savings or risk pools; others require network providers.
14. Who can join a medical aid scheme?
South African residents, subject to the scheme’s rules.
15. Is medical underwriting required?
Yes. Applicants must disclose medical history.
16. Can waiting periods apply?
Yes:
Up to 3-month general waiting period
Up to 12-month condition-specific waiting period
Late joiner penalties for members over age 35 with no prior cover
17. What are late joiner penalties?
Additional contribution loadings applied to members who join after age 35 without continuous prior medical scheme membership.
18. Can my application be declined?
No. Registered medical schemes cannot refuse membership, but they may impose waiting periods or late joiner penalties.
19. Can I add dependants later?
Yes, subject to underwriting and waiting periods.
20. How do I use my medical aid at a doctor or hospital?
Present your membership details. Providers either claim directly from the scheme or you submit the claim for reimbursement.
21. Do I need pre-authorisation for hospital admissions?
Yes. Planned hospital admissions require pre-authorisation.
22. What happens in an emergency?
Emergency treatment is covered, but you must notify the scheme within the required timeframe.
23. What is a Designated Service Provider (DSP)?
A DSP is a provider contracted with the scheme for PMB treatment. Using non-DSP providers may result in co-payments.
24. What are co-payments?
Amounts payable by the member when using non-network providers, certain procedures, or specific medicines.
25. Can I choose any specialist?
Yes, but charges above scheme rates may result in shortfalls.
26. How are contributions calculated?
Contributions are based on:
Plan selected
Number of dependants
Income band (for some schemes)
27. Do contributions increase annually?
Yes. Increases are typically implemented annually and approved by the Council for Medical Schemes.
28. Do medical aid contributions qualify for tax credits?
Yes. Members receive a monthly medical scheme fees tax credit from SARS.
29. Can I downgrade or upgrade my plan?
Plan changes are usually allowed at year-end or under specific qualifying life events.
30. What happens if I miss a contribution?
The scheme may suspend benefits or terminate membership after non-payment.
31. Can I cancel my medical aid?
Yes, subject to notice periods and scheme rules.
32. How are claims submitted?
Providers typically submit claims electronically. Members can also submit claims via app, email, or portal.
33. How long does claims processing take?
Usually within a few working days, depending on the scheme.
34. What if my claim is rejected?
You will receive a reason for rejection. You may:
Submit additional information
Appeal the decision
35. How do I lodge a formal complaint?
First escalate internally within the scheme. If unresolved, you may approach:
The Principal Officer of the scheme
The Council for Medical Schemes (CMS)
36. What documentation is required for disputes?
Membership number
Claim statement
Detailed invoice
Supporting medical motivation (if applicable)
