What does medical aid cover in South Africa?

Layer one: Prescribed Minimum Benefits. Every scheme, on every plan, must pay the diagnosis, treatment and care costs of PMB conditions in full, without a co-payment or deductible, if you follow the scheme's rules such as using its designated provider. The CMS says PMBs cover 271 medical conditions (Diagnosis Treatment Pairs) and 26 chronic conditions (the Chronic Disease List), and any emergency medical condition. Exclusions do not apply to PMBs. The CMS gives the example of septicaemia after cosmetic surgery: the cosmetic surgery is excluded, but the septicaemia is a PMB and must be covered.

Layer two: your plan's own benefits. Anything not on the PMB list is decided by the plan: which benefits exist, the annual limit, which providers you must use, whether you need pre-authorisation and whether a waiting period applies. Two members of the same scheme can have very different cover for these services.

Read the prescribed minimum benefits guide for the PMB detail.

The plan type tells you where to look first.

Real examples. Genesis's MED-100 covers planned and emergency admissions and basic dentistry, and all other day-to-day costs are self-funded. Discovery Health Medical Scheme's Classic Core is a hospital plan with no medical savings account. Discovery's Classic Saver has a savings account, and its Classic Comprehensive adds a limited Above Threshold Benefit. KeyHealth's Silver plan adds enhanced day-to-day cover and dental cover, and its Platinum plan adds increased dental cover and out-of-hospital mental health.

See the hospital plan guide, hospital plans versus comprehensive plans and the day-to-day benefits guide.

What is guaranteed. The Regulations to the Medical Schemes Act list chronic conditions that are PMBs, and they include Bipolar Mood Disorder and Schizophrenia. For a diagnosed PMB condition the scheme must pay diagnosis, treatment and care in full when you use its designated provider. PMBs are diagnosis-based, so the question is whether your diagnosis is a PMB, not whether you saw a psychologist or a psychiatrist. The full list is Annexure A of the Regulations on the CMS website, and your doctor can tell you if a diagnosis is a PMB.

What is plan-specific. Sessions with a psychologist for conditions that are not PMBs come from your plan's out-of-hospital benefits, if any. Examples stated in 2026 documents:

• KeyHealth's Gold and Platinum plans include out-of-hospital mental health cover.
• Genesis says designated service providers apply to some benefits, for example mental illness.
• Profmed's 2027 benefits page adds a mental health assessment to Preventative Care.
• Discovery's app includes digital mental health.

Affinity Health includes unlimited 24/7 telephonic consultations with a nurse, doctor or mental health professional, but it is insurance, not a medical scheme, and does not have to cover PMBs.

What to ask. Does the plan cover a psychologist, psychiatrist or counsellor out of hospital? How many sessions or how many rand a year? Is there a network? Does it need a referral or pre-authorisation? And if the diagnosis is a PMB, ask the scheme to treat it as one in writing.

We could not find a braces or orthodontic benefit in the 2026 scheme documents we checked, so we cannot say which plan pays for braces, and we will not guess. The PMB material we hold does not mention braces, although we did not check every diagnosis-treatment pair. Treat braces as a plan-specific benefit that may be limited, excluded, or held within a specialised dentistry limit, and ask whether a specific condition qualifies as a PMB.

What we can tell you from those documents:

• Bankmed added a children's preventative dental benefit for ages 3 to 17 for 2026. That is preventative dentistry, not braces.
• Umvuzo's top Extreme option lists specialised dentistry of R15 700 per beneficiary per year. The page does not say whether that includes orthodontics, so ask.
• Waiting periods apply. A scheme may impose a general waiting period of up to three months and a condition-specific waiting period of up to 12 months on new members.

Before you sign a treatment plan, ask your orthodontist for the procedure codes and full cost, and ask the scheme in writing what it will pay, whether the limit resets each year and whether there is a lifetime or age limit. Do not pay a large deposit before you have that answer. See co-payments and sub-limits.

Dentistry is normally a day-to-day benefit. Plans that state dental cover in their 2026 information:

"Basic" and "specialised" dentistry are different benefit categories with separate limits, so check both. Health insurance is different again: Dis-Chem's MyHealth Core, which is not a medical scheme, lists basic dentistry, and Oneplan's Health Plan, also insurance, applies a 90-day waiting period to dentistry.

Optometry is also a day-to-day benefit, usually with a limit per person and a network.

• Umvuzo's only network is the PPN network for optometry, and using a non-network optometrist reduces benefits.
• Sasolmed's Restricted Network Option uses designated providers for optometry.
• LA Health's LA Active includes optical within its Extended day-to-day benefit.
• Medshield's MediCurve includes essential optical cover through network providers.
• Remedi raised frame and lens optical limits by 5% for 2026.

Health insurance products state their own limits. Dis-Chem's MyHealth Core gives 1 eye test and 1 pair of glasses every 24 months, and Affinity Health's day-to-day plans include optometry every 24 months, while Oneplan applies a 12-month waiting period to optometry. Laser eye surgery was not mentioned in the scheme documents we checked, so ask the scheme before booking.

We found no frail care or nursing home benefit in the 2026 scheme documents we reviewed, and the PMB material we hold does not make long-term frail care a Prescribed Minimum Benefit. Do not assume it is covered.

Hospital plans pay for hospital admissions, which is a different thing from long-term custodial or frail care. Ask the scheme these questions in writing:

• Does the plan pay for a sub-acute, step-down or hospice facility after a hospital stay, and for how long?
• Is there a rand or day limit, and is pre-authorisation needed?
• Does it pay for home nursing?

KeyHealth lists an Alignd Palliative Care Programme as an additional benefit on its 2026 site. Some gap cover products, for example Sanlam's, list a step-down facility benefit, but gap cover only tops up what your scheme has paid and is insurance, not a medical scheme. Read our guide to medical aid for pensioners if you are planning for older age.

1. Get the plan's benefit guide or schedule from the scheme's website or app. It is the document that counts, not the marketing page.
2. Find the benefit by name: psychology, orthodontics, specialised dentistry, optometry, sub-acute care. Note the limit, the network, the waiting period and whether authorisation is needed.
3. Ask for a written answer with the procedure or tariff codes from your provider.
4. Check whether it is a PMB. If so, you are entitled to full payment when you use the designated provider, and to no co-payment if you could not reasonably reach one.
5. Ask about waiting periods if you joined recently. See waiting periods and exclusions.

If a scheme refuses a benefit you think is a PMB, dispute it in writing, then complain to the CMS at [email protected] or on 0861 123 267, with proof you used the scheme's internal process first. See how to claim from your medical aid. The CMS is reviewing PMBs, but we found no change to the PMB list gazetted as at 29 September 2026, and no section of the NHI Act had been proclaimed.