Questions to ask before joining a medical aid scheme (with what a good answer looks like)

• Is this a registered medical scheme, an open scheme or a restricted scheme? Open schemes must accept any applicant who applies and can pay. Restricted schemes serve a particular employer, profession, industry, association or union.
• Does the plan cover Prescribed Minimum Benefits in full?
• Who is the administrator, and where do I complain?

A good answer: a scheme registration and a clear yes on PMBs. If the product is called health insurance or gap cover, it is not a scheme, does not have to cover PMBs, and complaints go to the National Financial Ombud, not the CMS. See medical aid vs health insurance.

• Will I have a general waiting period, a condition-specific one, or both, and for how long?
• Will my previous cover count, and what proof do you need?
• Does a late joiner penalty apply, in which band, and what will my contribution be?

A good answer: specific periods, in writing. The Medical Schemes Act allows at most three months general and 12 months condition-specific if you had no cover for 90 days or more. With a shorter gap after previous cover, the scheme can impose only one of them, and not on PMB treatment. These are maximums, and a scheme may impose less.

Penalties depend on your age and your years of creditable cover. If you are 35 or older they run from 5% to 75% of your part of the contribution, and they can follow you to another scheme. See late joiner penalty.

• At what rate does it pay hospitals and specialists? Is that 100% of the scheme rate, or more?
• What co-payments apply to scopes, scans and joint replacements?
• Is there day-to-day cover, and is it a savings account, an above-threshold benefit or nothing?
• What are the sub-limits for dentistry, optical and specialists?
• Do I need gap cover with this plan?

A good answer: numbers, not adjectives. Ask for the benefit schedule and check it yourself. See gap cover explained.

• Is this a network plan, and which hospitals, doctors and pharmacies must I use?
• Are my GP, my specialist and the nearest hospital on the list?
• What does it cost if I use a provider outside the network?
• Who is the designated service provider for PMBs and chronic medicine?

A good answer: a named list and a stated penalty. For example, Bestmed's Beat1 Network charges a R15 025 co-payment for voluntary use of a non-network hospital. A network plan is only cheap if your providers are on it. See network vs traditional plans.

• Which chronic conditions are covered, and is my medicine on the formulary?
• How do I register a chronic condition, and from when is it paid in full?
• What are the maternity benefits, and what waiting period applies if I am planning a family?

A good answer: the Chronic Disease List conditions are covered as PMBs on every option, with the scheme's designated provider and formulary. Anything else depends on the plan. See prescribed minimum benefits and the maternity benefits checklist.

• What is the contribution for my household, and on what date does that price apply?
• What increase should I expect for 2027, and when does it start?
• Can I move options later, and do waiting periods apply?

A good answer: an exact figure and date. The CMS recommended in Circular 20 of 2026 that schemes anchor 2027 increases at 3.8%, but it is a benchmark, not a cap. Fedhealth said 60% of members would see an average weighted increase of 8.9%, and Medshield announced a 7.9% weighted average. Discovery deferred its 2026 increases to April. See medical aid increases for 2027.

Within one scheme, the Act allows no new waiting period when you move options, unless one is still running.

• What is the scheme's internal complaints process and how long does it take?
• Which broker or consultant is responsible for advising me?

A good answer: clear steps. You must use the scheme's own dispute process first, then you may complain to the CMS with a completed complaint form and proof that you escalated. The CMS acknowledges in writing within six working days, and aims to finish within 120 calendar days of receiving the scheme's response and documents. Brokers are regulated by the CMS too. See how to complain to the CMS.