Medical scheme options generally combine two broad categories of benefits: major medical cover (often referred to as a Core Plan or “Hospital Plan”) and day-to-day healthcare benefits. The balance between these depends on the option selected. Some options focus on essential hospital and chronic care, while others provide more extensive benefits for everyday healthcare.

All registered medical scheme options must provide the applicable Prescribed Minimum Benefits (PMBs), as required by the Medical Schemes Act. These cover qualifying emergency medical conditions, specified medical conditions and certain chronic conditions, subject to the applicable treatment protocols and designated service provider requirements.

More comprehensive options may offer benefits beyond these minimum requirements, including higher reimbursement tariffs, broader provider networks and more extensive cover for certain treatments, prostheses and medicines.

Core benefits are primarily designed to protect members against the potentially high costs of serious illness, accidents and hospital treatment.

Benefits typically include:

• Hospital admissions, surgery and related hospital expenses.

• Specialist and diagnostic services associated with hospital treatment, including anaesthesia, pathology, radiology, scopes and scans, subject to the option’s rules.

• Certain day procedures, which may include scopes and selected dental or surgical procedures, depending on the option.

• Chronic disease management and qualifying chronic medication.

• Disease management programmes for certain serious or ongoing conditions, such as cancer, diabetes and kidney disease requiring dialysis.

• Selected preventative healthcare, such as screening, vaccinations and health assessments, depending on the option.

The level of cover can vary considerably. Some options focus on PMB requirements and use designated hospital and provider networks to keep contributions affordable. Others offer broader benefits, higher specialist reimbursement tariffs (for example, 100%, 200% or more of the scheme tariff) and greater flexibility in choosing healthcare providers.

Importantly, a stated reimbursement level is generally calculated against the scheme’s own tariff, not necessarily the amount charged by the healthcare provider. Even a higher reimbursement percentage does not guarantee that the full account will be paid.

Day-to-day benefits help fund more regular healthcare expenses, such as GP consultations, acute medication, certain specialist consultations, blood tests and other out-of-hospital services. Dental and optometry benefits may also be included.

The extent of cover depends on the option selected. Some options provide limited benefits through designated healthcare networks, while others offer defined annual benefits, a medical savings account or a combination of savings and additional insured benefits.

Although terminology varies between schemes, the following descriptions provide a useful general guide:

Core / Hospital Plan: Major medical benefits focused on hospitalisation and specified healthcare needs, with applicable PMBs and any additional chronic or preventative benefits included in the option.

Saver: Major medical benefits combined with a medical savings account to fund eligible day-to-day expenses. Once the available savings have been used, members may need to pay further routine expenses themselves unless another benefit applies.

Comprehensive: Major medical benefits combined with a medical savings account and, on some options, additional insured day-to-day benefits. Certain options also use an insured self-payment gap or threshold arrangement, under which additional day-to-day claims may become payable once specified conditions have been met.

Traditional: Major medical benefits combined with defined day-to-day benefits, often subject to annual limits or separate benefit sub-limits rather than a medical savings account.

Network / Capitation-based: Major medical benefits combined with specified primary healthcare services delivered through designated providers or networks. Some arrangements use capitation, whereby providers receive a predetermined payment for an agreed package of services. These options can be more affordable but may involve restrictions on provider choice and access.

These categories are not mutually exclusive, and not every scheme offers all of them. The actual benefits, limits, networks and conditions in the option’s benefit guide and registered rules determine the cover available.

As a general rule, lower-cost options tend to offer more restricted benefits, provider networks or choice, while higher-cost options may provide broader benefits and greater flexibility. However, price alone does not determine the quality or suitability of cover. The benefit structure, network arrangements, exclusions, co-payments and reimbursement limits all matter.

A serious accident, major operation, cancer diagnosis or other complex medical condition can result in substantial healthcare expenses, potentially running into hundreds of thousands or even millions of rand.

For this reason, we generally recommend considering a medical scheme with adequate major medical cover as the starting point for healthcare protection. Even a more basic hospital-focused option can provide an important level of financial protection against eligible major medical expenses, alongside the statutory PMB benefits.

Where affordability is a concern, a lower-cost medical scheme option may be worth considering before relying solely on health insurance. The aim is to establish a suitable foundation of medical protection and then assess whether additional day-to-day benefits or complementary products are appropriate.

Health insurance is not the same as medical scheme cover. Local health insurance products generally pay defined benefits in accordance with their policy terms, rather than funding eligible healthcare expenses on the same basis as a registered medical scheme. Depending on the policy, the amount paid may be substantially less than the actual cost of treatment, leaving the insured person exposed to significant expenses.

International health insurance can operate differently and may provide broader medical expense cover, depending on the policy. However, products should be compared on their actual terms, exclusions, limits and scope of cover rather than assumed to be equivalent.

The appropriate solution will depend on your healthcare needs, affordability and the level of financial risk you are prepared to retain.