Your medical aid checklist


Medical costs are enough to make you sick. And medical aid membership fees keep escalating so cost has become a major consideration when choosing a health scheme. Be careful, though – choosing the cheapest option may end up costing you more in the long run if your scheme doesn’t pay out enough to cover your medical expenses. Do your homework and make sure you pick the right scheme for your needs. For a list of registered schemes call the Council for Medical Schemes (CMS) on 0861-123-267 or go to You can then contact the schemes individually or go to their websites to get details of their costs and benefits. You can also ask a financial adviser or go to for more information.

Issues to consider before deciding

Payout rate

Consult the National Health Reference Price List (NHRPL) to find out what percentage of medical costs the scheme pays. The list is compiled by the health department and suggests prices for various procedures. Doctors and specialists often charge much more than these prices; the NHRPL tariffs are just a guide. For example, it could say a visit to your GP should cost R190 but doctors don’t have to stick to this and may bill you for much more. So if your medical aid pays out 100 per cent of the NHRPL tariff you may still have to pay the difference.

Say the list says a procedure should cost R100 and the doctor charges R300, if your scheme pays 200 per cent of the recommended price it means it will pay R200. The smaller the percentage the more you have to pay to make up the difference.

Who may treat you?

More and more schemes are limiting members to specific hospitals and doctors with whom they’ve reached an agreement on the tariffs they charge. Make sure your scheme has such an agreement with hospitals and doctors in your area.

High-risk diseases

The scheme should provide enough cover for conditions that may run in your family, such as heart disease or diabetes. If you have a high risk of getting cancer make sure the scheme provides for full treatment. Many of the cheaper schemes provide cover for cancer treatment at state hospitals only.

Chronic medication

Find out how much your scheme pays for chronic medication for conditions you may be at risk of getting such as asthma, diabetes, high cholesterol or blood pressure problems. Some schemes limit their cover and may insist you use generic versions of medication.

Hospital costs

The sharp increase in private hospital tariffs means hospitalisation can bring financial ruin if you don’t have enough cover. This is why many South Africans with a limited budget opt for a cheaper medical scheme that provides extensive hospital cover but little else.

Make sure the cover is sufficient as the rates charged by surgeons and other specialists are particularly high. The hospital cover should include dialysis and prostheses.

Day-to-day expenses

More and more schemes are reducing their cover for one-off visits to doctors and the medication they may prescribe. The schemes may insist these are paid for from a savings account or so-called alternative saving instrument. The money for this account comes from your monthly premiums. If the account is depleted you have to pay the bill. If you can afford only limited cover for day-to-day expenses try to save an extra amount every month to pay for unforeseen medical costs.

Dental benefits

Medical schemes are reducing their cover in this regard and many pay for dental work from your savings account only. If you have children it’s better if dental costs are paid for from the scheme’s shared-risk fund.

-Helena Wasserman

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