How does medical aid work in South Africa?

Four different parties are involved, and people often mix them up.

• The scheme is the member-owned, not-for-profit fund that holds the money and decides what is paid. Discovery Health Medical Scheme, Bonitas and GEMS are schemes.
• The administrator runs claims, call centres and systems for the scheme. Discovery Health Medical Scheme, for example, is administered by Discovery Health (Pty) Ltd and describes itself as independent from the Discovery Group. The CMS counted 33 administrators in 2024/25.
• Managed care organisations run networks, formularies and authorisations on behalf of schemes. The CMS counted 43.
• Brokers are optional advisers. The CMS counted over 10 000 brokers and brokerages.

A scheme is either open, which means it must accept any person who applies and can pay, or restricted, which means it serves one employer group, profession, industry, association or union. Most restricted schemes cannot be joined by the public.

Your contribution is normally split into two parts.

1. The risk pool: the shared money that pays for hospital admissions, Prescribed Minimum Benefits and big claims for everyone on the plan.
2. A medical savings account (MSA): on saver and comprehensive plans, a slice of your contribution is held in your name for day-to-day costs such as GP visits and acute medicine.

Take Discovery Health Medical Scheme's Classic Saver plan in 2026. The main member pays R4 850 a month in total, made up of R3 880 for the risk pool and R970 for the savings account. Its Classic Core hospital plan costs R3 905 a month for the main member and has no savings account at all. See our medical savings account guide for how much each scheme puts into savings.

By law contributions may be set only by income and/or the number of dependants. The scheme cannot charge you more because you are older, female or sick. The one exception is the late-joiner penalty, explained below. Some plans are priced in income bands: Discovery's KeyCare Start costs from R1 436 to R3 765 for the main member depending on income, from 1 April 2026.

Every scheme sells a range of plans. The names differ, but most fall into five types. The examples are Discovery Health Medical Scheme plans, main-member prices from 1 April 2026.

Other schemes price their plans differently, so use the scheme pages for their own figures. For the trade-offs between cheaper and richer plans read our hospital plan guide and the comparison of hospital plans and comprehensive plans, and see network and traditional plans for what a network means in practice.

Every registered scheme, on every plan including the cheapest, must cover Prescribed Minimum Benefits (PMBs). The CMS says PMBs cover a limited set of 271 medical conditions (the Diagnosis Treatment Pairs) and 26 chronic conditions (the Chronic Disease List). A CMS slide dated 17 August 2026 refers to 27 chronic conditions, so the count is worded differently in different CMS documents. PMBs also include any emergency medical condition.

The rules that matter to you:

• The scheme must pay PMB diagnosis, treatment and care in full, with no co-payment or deductible, provided you follow the scheme's rules.
• The scheme may require you to use its designated service provider (DSP). If you choose someone else voluntarily you can be charged a co-payment. If the DSP could not treat you without unreasonable delay, or none is within reasonable distance, no co-payment may be charged.
• Exclusions do not apply to PMBs. The CMS gives the example of septicaemia after cosmetic surgery: the septicaemia is a PMB even though the surgery was excluded.
• In an emergency you may go to the nearest facility even if it is not a DSP.

The CMS's PMB review is still under way. It is working on a primary healthcare package and we found no change to the PMB list gazetted as at 29 September 2026. Read the full prescribed minimum benefits guide and our page on emergency and ambulance cover. Outside PMBs every benefit has a limit and cheaper plans often restrict you to a network. Most providers claim directly from the scheme, and our guide to how to claim from your medical aid covers the pay-and-claim-back route.

Open schemes must accept you, but they can still apply rules that protect the fund.

Waiting periods. If you were not covered by any scheme for at least 90 days before applying, the scheme may impose a general waiting period of up to three months and a condition-specific waiting period of up to 12 months. These are maximums, and a scheme may impose shorter ones or none. Switching within 90 days does not automatically remove waiting periods: depending on how long you were previously covered, one of the two may still apply, but not to PMB treatment. No waiting period may be imposed on a child born during your membership or when you move between options within the same scheme.

Late-joiner penalties. A late joiner is an applicant or adult dependant aged 35 or older at application, unless continuously covered since before 1 April 2001 (with no break of more than three consecutive months). The band depends on your age minus 35 minus the years of cover you can prove:

For example, a 45-year-old with no proven earlier cover has 10 years counted (45 minus 35), which is the 25% band. Only that person's portion is loaded, and the penalty can follow you to another scheme. Full detail is in our guides on waiting periods and exclusions and the late-joiner penalty.

Contributions rise every year. For 2026, Alexforbes analysis reported by the Daily News on 29 October 2025 showed announced increases of 9.9% at Momentum, 9.6% at Fedhealth, 8.88% at Bonitas, 8.46% at Medihelp, 7.2% at Discovery and 6.8% at Bestmed, an average of 8.8% for the big open schemes. Discovery deferred its increase to 1 April 2026, so its effective increase over the year was about 5.4%.

For 2027 the CMS recommended in Circular 20 of 2026 that schemes anchor increases at 3.8%. That is a benchmark, not a cap, and the CMS itself says private medical inflation usually runs 2 to 3 percentage points above CPI. As at 29 September 2026 only a few schemes had published: Fedhealth reported 8.9% for 60% of its members and Medshield a 7.9% weighted average. See medical aid increases for 2027 and how much medical aid costs.

SARS gives a medical scheme fees tax credit. For 2026/27 it is R376 a month for the main member, R752 a month for the member and one dependant, and R254 a month for each additional dependant. It is non-refundable and does not carry over. See the medical aid tax credit guide.

Gap cover, hospital cash plans and primary care insurance are health insurance products, not medical schemes. They are exempt from the Medical Schemes Act, do not have to cover PMBs, and complaints about them go to the National Financial Ombud, not the CMS. Gap cover only works alongside a scheme: from 1 April 2026 its maximum benefit is R226 881.03 per insured person a year. Read gap cover explained and medical aid versus health insurance.

National Health Insurance (NHI) has not changed your cover. The NHI Act was signed in May 2024, but as at September 2026 no section had been proclaimed and the Constitutional Court has reserved judgment on two challenges. Your scheme's benefits are unchanged. See NHI and medical aid.

Ask your scheme to fix the problem first and keep the reference numbers. The CMS says complainants must exhaust the scheme's internal dispute process before it steps in. Then send the CMS a completed complaint form and proof that you escalated to [email protected], or phone its Customer Care line on 0861 123 267.

The CMS says it acknowledges a complaint within 6 working days, refers it to the scheme for comment, and aims to resolve it within 120 calendar days of receiving the scheme's response and documents. You should submit preferably within 3 years. In 2024/25 it registered 1 962 complaints and resolved 1 879. Our complaints guide and complaint letter template help you prepare. Official source: CMS complaints procedure.