How to manage your medical aid

Jeannie Berg, pharmacist and diabetes nurse educator, offers good practical tips on how to manage your medical aid.

Healthcare has become hugely expensive. Even a minor operation can have you digging into your long-term savings. The high cost of hospital stays, specialist fees and other medical expenses (including medication) makes it important to have at least some form of medical cover: medical aid or medical insurance.

Let’s start off by differentiating between medical aid and medical insurance. Although, these terms are often used interchangeably, there are significant differences between them.

Medical aid

A medical aid scheme focusses on providing members with cover for expenses associated with necessary medical treatment. Members are often obliged to use healthcare specialists who belong to a provider’s network, and conditions rule which treatments are covered, but taking scheme tariffs into account, the amount you’re paid out will depend on what medical attention you need.

Medical insurance

Medical insurance, however, is intended to ensure that when you need funds for medical purposes, you receive a fixed lump sum. This amount won’t differ, regardless of the type of treatment that’s required or which healthcare providers you use. Here you would pay the health providers up front and the insurance will give you the agreed upon lump sum and you have to sort it out.

Governed strictly in SA

Both medical aid and medical insurances are governed very strictly in South Africa. All medical aid schemes are regulated by the Medical Schemes Act and governed by the Council for Medical Schemes. Medical insurance is regulated by the long-term insurance act and governed by the Financial Services Board.

By law, medical aid providers are required to provide prescribed minimum benefits (PMB) for a list of chronic disorders, such as asthma, cardiac conditions, diabetes, hypertension, etc. There are 26 conditions that are covered.

However, medical aids still decide what drugs are on their ‘essential drug list’ for a certain condition. If you use a drug for a condition that is not on this list, chances are that you might have to pay in full for it, or a bigger co-payment is required.

So, how do you manage your medical aid?

  • It’s like a bank account. You have a certain amount of “money” in it and you need to take care that you don’t waste it. You need to check all the claims that go through it.
  • Use your options carefully. Do you need to see a doctor, or can a pharmacist help you? Pharmacists are highly trained and many have done courses on primary healthcare. This means that they are able to help you with OTC medicine for conditions like sinus, colds and pain, without you having to see a doctor and use your doctor visits unnecessarily. Pharmacists are drug specialists. Many drugs have generic alternatives and are often priced at a fraction of the cost. Usually, medical schemes will pay in full for generic options. Generic medicine has the same active ingredient as the original brand, and should be just as effective with the same strength and dosage. Your pharmacist can guide you for the best generic options, especially if you are on chronic medication. If you do still insist on the original drug, you will have to pay some or all of it.
  • Gap cover is a good idea if you have any worries about potential co-payments. This cover could help avoid costly out-of-pocket in-hospital medical fees. Gap health insurance works with your medical plan to close in-hospital payment gaps if your medical aid benefits are exhausted. Some medical aids also offer Gap cover. It’s worthwhile looking into this.
  • Managed Care Benefits are offered by medical aids and it’s a good thing to look into this. These programmes typically help those who need to manage chronic conditions, such as diabetes, cancer, and HIV/AIDS. They are usually funded by your medical contribution’s risk portion and not from your savings account, meaning that you are getting the most from your benefits while receiving the medical care that you need.
  • Always ask questions. You are the client/patient and entitled to ask what you are unsure of.
  • If you need to be hospitalised for a routine procedure, ensure that the hospital and doctors are on your medical scheme list.
  • Ask your doctor or specialist how much they will charge and ask them to explain the bill in terms of your medical aid coverage. If your medical aid doesn’t cover enough of the doctor’s fee, ask him if he would be willing to negotiate a lower rate.
  • Ensure that you have obtained the necessary pre-authorisation for procedures and that the correct ICD-10 codes are being used.
  • Remember that you’re the owner of your medical aid “bank account”. Use it wisely. Check your statements to make sure that your funds are being well spent by yourself and your beneficiaries.
  • Don’t buy OTC medicine unnecessary, because your medical aid pays for it. Remember that when medical aids budget for the following year, they also take into consideration the spending trend of the patients. This affects your following year’s contribution.
  • Don’t do someone a favour by buying something on your medical aid. This is fraud and can get you into serious trouble.
  • The best you can do for yourself is to have a good medical aid that is right for your style of living. If you have many chronic complications, you need a more comprehensive plan. If you are young and healthy, you can opt for a lower plan. All plans include a hospital plan.

Looking after your health by having a good lifestyle, which includes healthy eating, stress management and exercise is already a great way to save on medical expenses.

Jeannie Berg


Jeannie Berg is a pharmacist and accredited diabetes educator. She served as Diabetes Education Society of South Africa (DESSA) chairperson for four years and was a committee member for many years and served on an advisory board for South African diabetes guidelines as well. She also does online tutoring in diabetes management for The University of South Wales.

Header image by Adobe Stock