While regulators recommended contribution increases be capped at around 6 to 7 percent—roughly in line with consumer inflation of about 3 percent—several major schemes have raised rates well beyond that, as healthcare cost inflation runs at 9 to 11 percent.
Did You Know? Every registered medical scheme in South Africa is still required by law to cover Prescribed Minimum Benefits in full, which includes a defined list of around 270 conditions, the Chronic Disease List, and emergency care, regardless of a member’s savings or threshold status.
Expert Insight: The divergence between consumer inflation and healthcare cost inflation places immense financial pressure on households, shifting the burden of day-to-day medical expenses onto members’ personal savings and out-of-pocket spending.
Complexity and Rising Out-of-Pocket Expenses
The biggest change over the past decade is that medical aid has become far more complex. In the past, routine healthcare costs were widely covered, but today most day-to-day expenses are paid directly from medical savings or out of a client’s own pocket.
Members must carefully weigh up co-payments, sub-limits, designated service providers, network restrictions, and benefit limits. At the same time, specialists often charge well above scheme rates. Consequently, having medical aid and being fully financially protected are no longer the same thing.
Outside of Prescribed Minimum Benefits—which serve as a floor rather than a ceiling—members face significantly more exposure than many realize. Unanticipated out-of-pocket costs frequently arise when a claim is subject to a co-payment, a benefit limit, or a specialist charging above the scheme rate.
The Evolving Role of Gap Cover and Financial Advisors
As medical options introduce growing numbers of co-payments, sub-limits, penalties, and benefit restrictions, the role of gap cover has fundamentally shifted.
Advisors can no longer simply recommend a medical aid option; they must help clients understand how specific options work, where shortfalls may arise, and how concepts like penalties and designated service providers affect them. Advice must also be personalized based on healthcare needs, affordability, and family circumstances, as a younger family requires very different cover than someone approaching retirement.
However, gap cover itself is not unlimited. Under the Demarcation Regulations, gap cover claims are capped at an aggregate annual limit per beneficiary, adjusted annually for inflation. Very large shortfalls can still exceed this cap, making it vital that the underlying medical aid plan is structured correctly from the start.
Regular Reviews and Future Healthcare Planning
Because medical scheme benefits change, family circumstances shift, and healthcare needs evolve over time, advice is no longer a once-off conversation. Regular reviews help ensure that both medical aid and gap cover continue to provide the necessary level of protection.
Clients should speak to their broker or financial advisor regularly to ensure their coverage meets their changing healthcare needs.
Frequently Asked Questions
What is the recommended cap on medical aid contribution increases for 2026?
Industry regulators recommended that scheme contribution increases be capped at around 6 to 7 percent, which accounts for CPI plus 3 percent.
What medical conditions are registered medical schemes legally required to cover in full?
Schemes must cover Prescribed Minimum Benefits in full, which include a defined list of around 270 conditions, the Chronic Disease List, and emergency care.
Are gap cover claims unlimited under current regulations?
No. Under the Demarcation Regulations, gap cover claims are capped at an aggregate annual limit per beneficiary, which is adjusted each year for inflation.
How do you plan to adjust your healthcare planning to manage rising out-of-pocket medical expenses and benefit restrictions?
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