Medical aid in South Africa

Medical aid is a medical scheme, not an insurance policy

In South Africa the word "medical aid" refers to a medical scheme registered under the Medical Schemes Act 131 of 1998. Schemes are regulated by the Council for Medical Schemes (CMS), set up by section 3 of the Act. Products sold by insurers — gap cover, hospital cash plans, travel medical cover — are a different thing, regulated by the insurance laws (see gap cover and hospital plans).

Three rules of the Act protect you whatever scheme you choose:

• Community rating — section 29(1)(n): contributions may be set only on the basis of income, the number of dependants, or both. Not on age, sex, past or present state of health, or how often you see a doctor.
• No exclusion of applicants — section 29(3)(a): a scheme's rules may not exclude an applicant or dependant, except where a restricted scheme limits who is eligible.
• Prescribed Minimum Benefits — Regulation 8: every benefit option must pay a defined list of conditions in full (see prescribed minimum benefits).

Open schemes and restricted schemes

The figures come from the CMS Annual Report 2025/26, which counts 70 registered schemes, 36 administrators, 42 managed care organisations, 2,182 broker organisations and 7,793 individual brokers. The number of schemes has fallen from 144 in 2000. Beneficiaries rose from about 9.13 million in 2023 to 9.17 million in 2024.

If your employer has a restricted scheme, ask HR for its rules and benefit options before looking at open schemes: a scheme can only be compared with another once you know you are allowed to join it.

The 16 open medical schemes (CMS list, 31 March 2026)

Anyone can join these schemes. The list is the Council for Medical Schemes' register of schemes "registered in terms of the Medical Schemes Act (131 of 1998), as at 31 March 2026", printed in its Annual Report 2025/26. Alphabetical order, as on the register — Tulinde does not rank schemes.

The other 54 registered schemes are restricted — for the employees of a company, an industry or a profession (for example GEMS for government employees, POLMED for the police, Bankmed or Profmed). Ask your employer's HR first: if you are eligible for a restricted scheme, it belongs in your comparison.

What medical aid costs in 2026: the official averages

Each scheme sets its own contribution table per option, so there is no single price. The CMS publishes the average monthly contribution across all options (Tables 60 and 61, CMS Annual Report 2025/26). "Gross" includes the medical savings account; "risk" is the pooled part only.

For an average family (1 member, 0.45 adult dependant and 0.74 child dependant), the CMS puts the gross contribution at R6,204.78 a month in 2026, up 6.7% from R5,817.16 in 2025; the risk contribution rose 7.0% to R5,610.30. Gross contributions rose 6.8% on average for 2026, against projected CPI of 3.4%.

These are averages over every option, from hospital plans to comprehensive cover: your quote can be well above or below them.

Cheapest medical aid: the options the law allows

There is no official "cheapest medical aid" and Tulinde does not rank schemes. What the law does say is which kinds of cover cost less — and what each gives up:

Sources: the Medical Schemes Act and Regulations and the CMS Annual Report 2025/26, which also notes that the Low-Cost Benefit Option framework for schemes was still under review in 2026. The cheapest contribution is not always the cheapest year: add the co-payments and the out-of-pocket costs below. Each scheme's lowest and highest published 2026 contribution, side by side: compare medical aid schemes.

Waiting periods: what a scheme may and may not impose

Section 29A of the Act is the only source of waiting periods a scheme can apply. What you face depends on your cover in the last 90 days:

A condition-specific waiting period applies to conditions for which you received or were recommended advice, diagnosis, care or treatment in the 12 months before applying — the scheme may only ask for a medical report about that period (s.29A(7)), and it must pay for any tests it requires (Regulation 12).

Late-joiner penalties: the exact bands

Regulation 13 allows a scheme to add a late-joiner penalty to the contribution of a member or adult dependant who is 35 or older when applying (Regulation 11). People who were continuously covered since before 1 April 2001 without a break of more than three months are not late joiners. The penalty applies only to that person's share of the contribution, and it may follow you if you move scheme (Regulation 13(5)).

The band is found with the formula A = B − (35 + C): B is your age when you apply, C is your years of "creditable coverage" (earlier scheme membership, excluding years as a dependant under 21).

Example: you apply at 45 with 2 years of earlier cover. A = 45 − (35 + 2) = 8, so the band is 5–14 and the scheme may load your contribution by up to 25%. If you later prove more creditable coverage, the scheme must recalculate the penalty from that date (Regulation 13(4)); a sworn affidavit is accepted when documents cannot be found (Regulation 13(6)). These are maximums: the scheme's rules say what it actually applies.

How to compare medical aid cost honestly

There is no official "cheapest medical aid": each scheme publishes its own contribution table every year, and the right price depends on your income band, your dependants and the benefits you will actually use. Tulinde does not rank schemes. Compare like this:

1. Check the scheme is registered on the CMS list of regulated entities — and that the broker who advises you is accredited.
2. Ask for the rules and the benefit schedule of each option, not a brochure. The rules are what the scheme must pay (section 29).
3. Work out a full year: monthly contribution × 12, plus the co-payments and day-to-day limits for what your family used last year. A low contribution with a small savings account can cost more over a year.
4. Check the designated service providers (DSPs) for hospital and chronic medicine: using another provider can mean a co-payment (Regulation 8(2)).
5. Ask in writing which waiting periods and late-joiner penalty they will apply to you, with the section 29A paragraph and Regulation 13 band.
6. Check what you would still pay yourself: the CMS reports that out-of-pocket payments by scheme members reached R46.3 billion in 2024, led by medicines (35.09%) and specialists (28.47%) (CMS Annual Report 2025/26). Shortfalls on specialist bills are what gap cover is sold for.
7. Count the tax credit: SARS deducts a fixed monthly credit per member and dependant from your income tax, whatever the option — see medical aid tax credit.

If your scheme refuses to pay

First use the scheme's own dispute process. If it fails, complain to the CMS by e-mail to [email protected] with the complaint form, proof that you escalated to the scheme, and your accounts (CMS). The CMS asks for complaints preferably within 3 years. Under section 47 the Registrar sends your complaint to the scheme, which has 30 days to reply; a decision can be appealed to the Council within 3 months (section 48). In 2025/26 the CMS registered 2,455 formal complaints. The CMS, its complaint form and contacts: Council for Medical Schemes. More on complaints and policyholder rights.

Sources

1. Council for Medical Schemes — Medical Schemes Act 131 of 1998 and Regulations (consolidated copy, Web Archive)
2. Council for Medical Schemes — Annual Report 2025/26 (copy tabled in Parliament, hosted by PMG)
3. Council for Medical Schemes — Regulated entities (medical schemes, administrators, brokers) (Web Archive)
4. Council for Medical Schemes — The Complaints Procedure (Web Archive)