Tips on Choosing a Medical Aid Plan for Next Year

At the end of each year, medical schemes provide a window period for members to change their plans, correctly known as “options”, for the following year. Here are some tips on what to consider when deciding on the option to best balance your expenses and needs in the year ahead.

Assess your past coverage

Look at your medical expenses over the past year and determine what portion the medical scheme paid from your risk benefit, how much was paid from your medical savings account (MSA), if you have one on your option, and how much you paid over and above that out of your own pocket.

Assess your future medical needs

Looking at your medical expenses for the past year will give you a rough idea of what they will be next year. Also factor in medical treatments or procedures that you may have to undergo in the coming year.

Read up on the scheme’s offerings

Take time to study the brochures from your medical scheme detailing the options and contribution rates for the coming year. Pay particular attention to:

• Changes to your option. Look at your option details for next year and take note of any benefits that may have changed. New benefits may have been added or existing ones may have been reduced.

• Designated providers and networks. Depending on the option, the scheme may only cover you in full if you use a hospital or health professional on the scheme’s list of designated service providers (DSPs), with which it will have a contractual agreement. Specifically look at which hospitals are on the list to ensure that there is one in your area.

• Risk benefits versus MSA. Look at what portion of the contribution goes towards the MSA, and what expenses will be paid from your risk benefits versus your MSA. This will give you an idea of how quickly your MSA will be used up over the year.

• Co-payments. Check on procedures, such as certain scans, that will require a co-payment, either from your MSA or from your own pocket.

• Pre-authorisation. Check on what procedures need pre-authorisation from the scheme before they will be covered.

• Prescribed minimum benefits. All medical schemes must, from your risk benefit, not your MSA, pay for the diagnosis and treatment of a list of life-threatening conditions (including chronic conditions) as prescribed by the Council for Medical Schemes and known as the Prescribed Minimum Benefits (PMBs). This list is available on the CMS website. In an emergency, any provider may be used, but otherwise the scheme may require you to use a DSP if it is to pay the bill in full.

• Medicine formulary. Check the scheme’s formulary of medicines to see whether medications you are likely to be taking will be covered.

• Benefit limits. Your cover will have an overall limit for the year and there will be sub-limits on individual procedures and conditions. Check whether these are appropriate for your expected needs.

• Wellness programs and incentives. Check on the scheme’s wellness and rewards programmes that promote healthy lifestyle choices. Engaging in these programmes can reduce your costs while encouraging healthier living.

Weigh your options

Look at other options offered by the scheme, comparing benefits and contribution rates with the option you are currently on. Weigh up whether it will be more cost-effective moving either to a cheaper option and paying more out of your own pocket, or to a more expensive option, where a higher portion of your medical bills will be paid by the scheme.

Consider using a broker

A medical scheme broker, who must be registered with the CMS (you can find a list of accredited brokers here), will advise you on how best to structure your medical scheme benefits. The broker fee comes out of your contributions: Currently, the maximum broker fee is the lesser of: R121.84 plus VAT per member per month or 3% of your total monthly contribution plus VAT. It is not compulsory to use a broker.

References

https://www.medicalschemes.co.za/medical-schemes-open-season-2026-how-to-choose-a-medical-scheme-or-benefit-option

https://bhfglobal.com/2024/11/12/key-considerations-in-selecting-medical-scheme-benefit-options-that-fit-your-health-needs/