Tag: medical aid schemes

Categories : Expert OpinionTags :

Opinion Piece: Medical Aid Cover is Changing – Are South Africans Prepared for the Gaps?

On By ModernMedia
Photo by Alex Green on Unsplash

By James White, Director: Sales and Marketing at Turnberry Management Risk Solutions

Medical aid remains essential for accessing private healthcare in South Africa, but it is no longer safe to assume it will cover the full cost of treatment. In 2026, industry regulators recommended that scheme contribution increases be capped at around 6-7% (CPI plus 3%), roughly in line with inflation, yet several major schemes have raised contributions well beyond that, with healthcare cost inflation broadly running at 9 – 11% against consumer inflation of about 3%. Medical aid options have also introduced growing numbers of co-payments, sub-limits, penalties and benefit restrictions. As a result, the role of gap cover has changed. What was once seen as an optional extra has become a critical safeguard against medical expense shortfalls, and it is now imperative that advisers and clients understand where medical aid cover may fall short and how those risks can be managed.

Healthcare cover is not what it used to be

The biggest change over the past decade is that medical aid has become far more complex. In the past, it was fairly simple to understand, and many routine healthcare costs were covered. Today, most day-to-day expenses are paid from medical savings or out of a client’s own pocket, and members must weigh up co-payments, sub-limits, designated service providers, network restrictions and benefit limits, all of which affect what a scheme will ultimately pay. At the same time, healthcare costs have continued to climb, and specialists often charge well above scheme rates. This means that having medical aid and being fully financially protected are no longer the same thing.

Every registered medical scheme is still required to cover Prescribed Minimum Benefits (PMBs) in full, a defined list of around 270 conditions, the Chronic Disease List, and emergency care, regardless of a member’s savings or threshold status. But PMBs are a floor, not a ceiling: outside of them, members are far more exposed than many realise.

Despite this, many people still believe they are adequately protected, without fully understanding the limitations of their medical aid. The reality often only becomes apparent when they need treatment. A claim subject to a co-payment, a specialist charging above the scheme rate, or a treatment subject to benefit limits can result in significant and unanticipated out-of-pocket costs.

Advice needs to evolve with the healthcare system

As the healthcare landscape has changed, the role of the adviser has changed with it. Recommending a medical aid option is no longer enough. Advisers also need to help clients understand how that option works, what it covers, where medical expense shortfalls may still arise, and how concepts such as co-payments, penalties, and designated service providers could affect them.

Advice also needs to be more personalised than in the past. Medical scheme options differ significantly, and the right level of cover depends on a client’s healthcare needs, affordability and family circumstances. A younger family with children, for example, may require very different cover from someone approaching retirement, even if both belong to the same medical scheme.

It’s also worth noting that gap cover itself isn’t unlimited. Under the Demarcation Regulations, gap cover claims are capped at an aggregate annual limit per beneficiary, a figure adjusted each year for inflation. Most claims fall comfortably within it, but very large shortfalls can still exceed the cap, which is one more reason the underlying medical aid plan needs to be right in the first place, not just the gap cover sitting on top of it.

This advice is no longer a once-off conversation either. Medical scheme benefits change, family circumstances shift over time, and healthcare needs evolve. Regular reviews help ensure that both medical aid and gap cover continue to provide the level of protection clients need.

A critical part of healthcare planning

The healthcare system has changed significantly over the past decade, and the way advisers approach healthcare cover needs to change with it. Medical aid remains essential, but it no longer provides the level of protection many people still expect. As a result, gap cover has evolved from an optional extra to a core part of protecting against medical expense shortfalls. Helping clients understand how their medical aid works, where shortfalls may arise, and how gap cover can address them has become an important part of modern healthcare advice.

As medical aid benefits, healthcare costs, and client needs continue to change, regular reviews are essential. By ensuring cover continues to reflect a client’s circumstances, and by explaining potential shortfalls before they arise, advisers can help clients make informed decisions and avoid unexpected medical expenses. Clients should speak to their broker or financial adviser regularly, to make sure their medical aid and gap cover continue to meet their healthcare needs.

Turnberry Management Risk Solutions (Pty) Ltd is an authorised Financial Services Provider (FSP no. 36571). Underwritten by Lombard Insurance Company, an Authorised Financial Services Provider (FSP 1596) and Insurer conducting non-life insurance business.

Categories : Expert Opinion Medical IndustryTags :

Reforming Prescribed Minimum Benefits Is the First Step to Affordable Medical Cover

On By ModernMedia
Dr Katlego Mothudi is the Managing Director of the Board of Healthcare Funders, an industry representative body for medical aid schemes, administrators and managed care providers.

By Katlego Mothudi

With plans in motion to roll out universal health coverage in South Africa, Dr Katlego Mothudi, of the Board of Healthcare Funders, argues that revising the compulsory prescribed minimum benefits that medical schemes must provide can be a tool to deliver meaningful improvements today while laying the foundations for a more sustainable healthcare system.

South Africa’s journey towards universal health coverage will not be defined by a single policy or piece of legislation, but by the practical reforms that make quality healthcare more accessible and affordable for more people. Achieving this goal requires, among other things, tackling structural barriers that continue to drive up the cost of medical scheme cover and place private healthcare beyond the reach of millions of people in South Africa. One of the most important, yet often overlooked, barriers is the outdated framework governing prescribed minimum benefits (PMBs).

PMBs are the set of conditions and services that every medical scheme is legally required to cover, regardless of the plan a member chooses. Their existence is critical, created with the intention of ensuring scheme members do not lose access to catastrophic care in the event of serious illness. PMBs ensure that members are not reliant on an over-burdened public sector during medical emergencies. And although this principle remains important, the framework has not kept pace with South Africa’s changing disease burden, evolving models of care, or the cost of delivering healthcare.

20 years of PMB limbo

Regulations made under the Medical Schemes Act require PMBs to be reviewed every two years. This must be carried out by the Department of Health together with the Council of Medical Schemes, provincial health departments and other stakeholders. In practice, this has happened only once, more than 20 years ago.

The current review process has been underway for close to a decade without conclusion. As a result, the outdated PMB framework has become one of the most significant contributors to medical scheme costs and thus an inefficient health policy. Actuaries advise that roughly 60% of a scheme’s budget goes towards funding PMBs before any other benefit is considered. This used to be approximately 40% when the PMB was amended in 2003.

The consequences of this laborious review process directly impact household budgets. The most basic scheme cover now costs a single beneficiary in the region of R1 600 a month, with a family of three facing around R4 000. For most working people in South Africa, that is simply unaffordable, and it is a significant reason why medical scheme membership has stagnated even as the population has grown. Furthermore, South Africa’s healthcare “missing middle” has grown to an estimated 8 million people who access private healthcare, paying out-of-pocket, without belonging to a medical scheme.

An out-of-date framework

If the PMB list were redesigned today, using current clinical evidence, the country’s evolving disease burden, and the realities of healthcare affordability, many of its benefits would likely look very different. The current framework no longer reflects what the system can sustainably provide. And because it consumes such a large portion of every scheme’s budget, it crowds out the very things that would make cover more affordable and more useful – primary care, early intervention and prevention.

At a recent Board of Healthcare Funders conference, Dr Fatima Hoosain, a specialist breast and endocrine surgeon, set out the numbers plainly: a mammogram and ultrasound cost in the region of R2 500. Left undetected until the disease has progressed, that same patient may require R100 000 in radiation therapy, R200 000 in chemotherapy, and, for HER2-positive cancers which typically can quickly spread from the breasts to other areas of the body, roughly R7 000 every three weeks for a year in targeted biological therapy. Early detection does not only save lives, but it is also, by a wide margin, the cheaper pathway. From a cardiology perspective, Dr Martin Mpe, president of the South African Heart Association, made the same point at the conference. He argued that the cheapest way to treat a heart attack is to prevent it, and that the system needs to start rewarding prevention rather than paying only for treatment after the fact.

Rather than expanding access, an outdated PMB framework has unintentionally limited it.

A PMB framework anchored in 1999-era diagnosis-and-treatment logic has little room for rewarding the prevention and early detection that would keep patients out of the expensive end of the system altogether. Importantly, reform does not mean stripping away protection. It means modernising the list so that mandatory cover reflects today’s clinical realities. It also means rethinking how the package is defined. The current approach is built around a long, condition-by-condition diagnostic list, a modern framework could instead focus on the essential health services people need most, including preventative care, primary healthcare services, medicines on an essential medicines list, and diagnostics on an essential diagnostics list. It could also emphasise the areas where the disease burden is greatest.

A core service package

This aligns closely with the Board of Healthcare Funders’ (BHF) recent commitment to explore a Core Service Package as a practical step towards universal health coverage. By focusing on the services that deliver the greatest health benefit within available resources, such an approach would place prevention and patients at the centre of the health system while creating greater flexibility to expand affordable access.

The BHF has previously worked to operationalise South Africa’s national Essential Medicines List (EML) within the private funding environment, partnering with MediKredit in 2021 to launch a NAPPI-coded mapping tool that helps funders align benefit design and claims systems with the EML, improve medicine access, and reduce out-of-pocket costs. This existing groundwork offers an affordable, prevention-oriented foundation on which a modernised PMB package could be built.

The evidence of where the current framework falls short is already available. Annually, the Council for Medical Schemes reports on out-of-pocket expenditure, which exceeded R40 billion last year. When people spend that much of their own money on healthcare, over and above their contributions, they are pointing directly to where their cover is failing.

A broader set of changes

PMB reform does not stand alone, and it will not by itself fix affordability. It is the entry point to a broader set of changes that reinforce one another. The most important of these is regulated tariff reform. South Africa currently lacks a transparent, predictable mechanism for setting provider prices, and this absence has driven costs upward for years. Allowing schemes and willing providers to negotiate fair tariffs, within a properly regulated framework, published for transparency, would bring discipline and predictability to pricing and give members clarity on what they are paying for.

Alongside this, permitting schemes to offer low-cost benefit options, a subset of the proposed revised PMBs and based on services rendered in the public sector clinics, would extend affordable, primary-care-based cover to millions of people in South Africa who currently fall outside the system and pay out-of-pocket for private care.

None of these reforms require new legislation or a wholesale restructuring of the health system. They can be pursued within the existing regulatory framework, and PMB modernisation is the logical place to begin, because it addresses the highest single cost in every member’s contribution and unlocks the room to fund better, more preventive care.

For members, this shift would be felt less as a change to their PMB entitlements and more as a change in what their contribution actually buys before a crisis ever occurs. Money currently locked into funding late-stage, high-cost treatment for conditions that could often have been caught earlier could instead support routine age- and risk-appropriate cancer screenings, cardiovascular risk assessments and blood pressure checks, diabetes screening and management support, and the kind of primary care consultations that catch problems while they are still cheap and simple to treat. None of this is about giving members less. It is about intervening earlier, so that fewer members ever need the R100 000 radiation course, the R200 000 chemotherapy regimen, or the cardiac admission that better screening or blood pressure control could have prevented.

There is an understandable reluctance to reopen the PMB framework, given how long the review has already taken and how contested the terrain can be. The longer reform is delayed, the greater the affordability pressures on households and the greater the strain on the broader health system.

Reforming prescribed minimum benefits is ultimately about far more than updating a list of conditions. It is about creating the flexibility to expand access, strengthen prevention and make medical scheme cover affordable for more people in South Africa.

*Mothudi is the Managing Director of the Board of Healthcare Funders, which represents around 45 medical aid schemes in South Africa, including GEMS and Bonitas.

*This piece was published by Spotlight – health journalism in the public interest. Spotlight aims to deepen public understanding of important health issues by publishing a variety of views on its opinion pages. The views expressed in this article are not necessarily shared by the Spotlight editors.

Categories : Medical IndustryTags :

Momentum Health Calls for a Shift from Healthcare Cost to Prevention Investment

On By ModernMedia
Pexels Photo by Thirdman

As South Africans face rising inflation, pressure from the burden of chronic disease and financial strain, Momentum Health is advocating for a stronger national focus on the prevention dividend: the long-term value created when South Africans use preventative healthcare, wellness programmes, screenings, health assessments and digital tools to manage health risks before they become serious and costly.

This comes as households, employers and the healthcare system face increasing pressure from affordability constraints, chronic disease and mental health challenges. Research referenced by Stellenbosch Business School has estimated that health-related productivity losses cost South Africa around R161 billion a year, driven by absenteeism, presenteeism and untreated mental health challenges.

Momentum Health believes the conversation needs to move beyond healthcare as an expense that pays only when people are ill. Instead, medical aid should be seen as an investment in helping people stay healthier for longer.

“Rather than paying claims after someone becomes ill, modern healthcare needs to focus on helping people understand their risks earlier, take action sooner and build healthier habits that can improve quality of life over time,” says Damian McHugh, Chief Marketing Officer at Momentum Health. “Prevention is one of the most practical ways to support both better health outcomes and greater financial resilience for South Africans.”

Prevention is becoming more urgent

South Africa’s health and economic realities make prevention increasingly important. PwC’s South Africa Economic Outlook notes that South Africa’s real GDP per capita declined by a cumulative 4.2% over the past decade, a signal often associated with pressure on living standards and economic stability.

At the same time, the country continues to carry a significant disease burden. Government and World Health Organisation reporting show that South Africa has made progress in controlling tuberculosis, with TB cases declining significantly since 2015 and treatment coverage improving to 79% in 2023. However, more than half of TB-affected households still face catastrophic costs, showing how illness can deepen financial vulnerability when people are diagnosed late or struggle to access care.

Mental health is also placing pressure on individuals, employers and families. SADAG’s Working Life Survey found that 52% of surveyed employees had been diagnosed with a mental health condition, with depression, stress, anxiety and burnout among the commonly reported conditions.

These figures show why prevention must be personal, practical and accessible,” adds McHugh. “Every member’s health risks are different. The more people know about their own health, the easier it becomes to make informed choices, use the right benefits and take action before problems escalate.”

Healthy habits can create long-term value

Regular health checks, screenings, physical activity, digital healthcare tools and ongoing health management can help members detect risks earlier and make healthier decisions more consistently.

Preventative care can also support employers and the wider economy. When people are healthier, they are more likely to be present, productive and able to participate fully at work and in their communities. This matters in a country where affordability pressures mean many people are looking for healthcare solutions that deliver tangible value, not only financial protection after illness occurs.

Behavioural incentives can play an important role in this shift. When healthy choices are recognised and rewarded, members are more likely to build routines that support their physical, mental and financial wellbeing. This is the principle behind Momentum’s broader health and wellness approach- making it easier for members to take control of their health before problems arise.

Prevention is personal

The next phase of healthcare will be increasingly personalised. Data, health assessments and digital tools can help members better understand their individual health risks and choose the most relevant actions, whether that means completing a screening, increasing physical activity, accessing care digitally or managing a chronic condition more proactively.

“Prevention works best when it is simple, personalised and part of everyday life,” says McHugh. “Our role is to help members connect the dots between their daily habits, their health outcomes and their financial wellbeing. That is how healthcare becomes more than a monthly contribution. It becomes an investment in a healthier future.”

Categories : Expert Opinion Medical IndustryTags :

Opinion Piece: How Medical Aid Regulation Changes Are Shaping the Future Demand for Gap Cover

On By ModernMedia

By Brian Harris, CEO at Turnberry Management Risk Solutions

28 July 2026 – Medical aid remains essential for accessing private healthcare in South Africa, but it does not always cover the full cost of treatment. While regulations such as Prescribed Minimum Benefits (PMBs) ensure that members have access to a defined level of care for certain conditions, medical schemes still apply tariff limits, treatment protocols, co-payments and other funding rules that can leave members exposed to out-of-pocket costs. At the same time, healthcare costs continue to rise, placing additional pressure on how schemes fund treatment. As a result, medical expense shortfalls are becoming increasingly common, making gap cover an essential part of helping clients manage their healthcare costs and protecting them against unexpected expenses.

Protection within limits

PMBs are a clear example of how scheme rules and funding limits influence what medical schemes ultimately pay for. They are designed to ensure that all medical scheme members have access to treatment for a defined list of emergencies, chronic, and life-threatening conditions. However, they do not provide unlimited funding for every treatment option, and there is often a misunderstanding about this.

When it comes to PMBs, cover is still subject to scheme rules, treatment protocols, formularies, and designated service provider requirements. In many cases, cover is also aligned to the level of care that would ordinarily be available in the public healthcare system. This becomes particularly important in areas such as oncology, where newer or more specialised treatments may fall outside what a scheme is required to fund in full.

As a result, members may still face co-payments, sub-limits, or shortfalls that need to be paid for out of pocket, even when the condition itself qualifies as a PMB.

How scheme rules create shortfalls

PMBs are only part of the picture when it comes to medical expense shortfalls. Even where treatment is covered, medical schemes reimburse according to their own tariffs and funding rules, while healthcare providers may charge significantly more. The difference between what the scheme pays and what the provider charges is the member’s medical expense shortfall.

At the same time, medical schemes use co-payments, benefit limits, Designated Service Providers (DSPs) and authorisation requirements to manage rising healthcare costs and keep contributions affordable. If these rules are not followed, or if treatment falls outside the approved funding structure, members may still need to pay part of the cost themselves.

This means that having medical aid does not always guarantee that treatment will be covered in full. Even where treatment is approved, members can still face significant out-of-pocket expenses.

Advice is essential

As funding rules become increasingly complex, advisers need to take on a more proactive role in helping clients understand and navigate the healthcare landscape. Many clients do not fully understand how PMBs, DSPs, funding rules and scheme tariffs affect what their medical aid will ultimately pay. The reality often only becomes clear at the claims stage, when members discover that they are responsible for part of the cost themselves.

Explaining these rules clearly, together with where medical expense shortfalls may arise, is therefore becoming an increasingly important part of the healthcare funding discussion. Regular reviews and clear guidance also help ensure that changes to scheme rules, benefits, and healthcare costs do not leave clients exposed to unnecessary or unexpected out-of-pocket expenses.

Future-proofing healthcare advice

Medical aid and gap cover should not be treated as once-off decisions. Scheme rules, pricing structures and healthcare costs continue to change, which means healthcare advice needs to be reviewed regularly to ensure that cover remains appropriate.

Helping clients understand how their medical aid works, where medical expense shortfalls may arise, and how gap cover can be structured forms an important part of responsible advice. Regular reviews also help ensure that changes to benefits, family circumstances or healthcare needs do not leave clients exposed to unnecessary costs.

As regulation continues to shape how healthcare is funded in South Africa, gap cover is becoming an increasingly important part of managing healthcare costs. Brokers and financial advisers play an essential role in ensuring their clients have medical aid and gap cover that together provide the right level of protection.

Turnberry Management Risk Solutions (Pty) Ltd is an authorised Financial Services Provider (FSP no. 36571). Underwritten by Lombard Insurance Company, an Authorised Financial Services Provider (FSP 1596) and Insurer conducting non-life insurance business.

Categories : Expert Opinion Medical IndustryTags :

Opinion Piece: Why Gap Cover Has Become a Non-negotiable Conversation for Advisers

On By ModernMedia
Photo by Alex Green on Unsplash

By James White, Director: Sales and Marketing at Turnberry Management Risk Solutions

Medical aid is essential for accessing private healthcare in South Africa, but it does not always cover the full cost of treatment. Shortfalls related to specialist fees, co-payments, and sub-limits, are an ongoing reality, leaving many medical aid members exposed to significant out-of-pocket expenses. This is why gap cover is no longer an optional conversation for advisers. As these shortfalls become increasingly common, clients rely on advisers to identify where cover may fall short and to explain how these risks can be managed. Gap cover plays an important role in addressing this challenge by covering the difference between what medical schemes pay and what providers charge, making it an integral part of the advice process.

Making gap cover part of the conversation

As medical expense shortfalls become increasingly common, addressing them is becoming part of a financial adviser’s responsibility. When recommending or reviewing medical aid, it is not enough to focus only on contributions and benefits. Advisers also need to ensure that their clients are fully aware that their medical aid may not cover the full cost of treatment, particularly where specialist fees, co-payments and sub-limits apply.

Areas where clients are likely to face out-of-pocket costs need to be explained clearly, together with how gap cover can reduce them. Advisers need to position gap cover not as an optional extra, but as an essential part of ensuring that clients are not left exposed to avoidable out-of-pocket costs.

The cost of not addressing shortfalls

If financial advisers do not discuss gap cover with clients, the impact is typically not felt immediately. However, the problem becomes clear when a claim arises. If a member receives  treatment expecting their medical aid to cover the full cost, and then ends up with a large bill for the shortfall, or has to pay a large co-payment upfront, this can result in significant dissatisfaction.

The reality is that medical expense shortfalls are no longer unusual, and both the size and frequency of these costs are increasing. Specialists may charge several times the scheme rate, while co-payments and benefit limits are increasingly used by medical aids to manage costs and keep premiums affordable. Without additional cover, patients must pay these costs out of pocket, and they can run into tens or even hundreds of thousands of rands.

This is why it is important that these gaps be raised upfront. Clients rely on their advisers to explain how medical aid works and what costs may arise, so they can make informed decisions before a claim happens, rather than being caught off guard by costs that place pressure on their finances.

What advisers should be explaining

Gap cover should form part of every discussion around medical aid, rather than being treated as an optional extra. When recommending or reviewing medical aid, it is important for advisers to highlight where out-of-pocket costs may still arise, including specialist tariff gaps, co-payments, sub-limits and network restrictions.

These risks need to be explained clearly, together with how gap cover can reduce them. Discussing this upfront helps clients understand what their medical aid will and will not pay, so they are not surprised by costs when they claim. It also ensures that decisions around cover are based on a clear view of the full healthcare funding picture, not only the monthly premium.

Over time, this approach builds trust and reinforces the adviser’s role in helping clients manage healthcare costs, rather than reacting to them after the fact.

Complete advice requires a complete view of healthcare risk

Medical aid remains essential, but it does not remove the risk of medical expense shortfalls, co-payments, or sub-limits. These are now a routine part of private healthcare and need to be addressed as part of the advice process.

Advisers have a responsibility to identify and explain these risks clearly, and to make them a consistent part of every client conversation.

Helping clients understand how their medical aid works, where shortfalls may arise, and how gap cover can address those gaps ensures that their cover reflects a complete view of their healthcare costs and is genuinely aligned to their needs.

Categories : Expert Opinion Medical IndustryTags :

Why Medical Schemes Must Own Healthcare Reform

On By ModernMedia
“Medical schemes have an enormous amount of power to change the trajectory of healthcare in this country – but only if they are willing to use it,” Lungile Kasapato, CEO of PPO Serve.

South African medical schemes have long borne the brunt of public frustration. Contribution increases have outpaced both wages and inflation, forcing many members to choose between healthcare cover and basic needs. But according to Lungile Kasapato, CEO of PPO Serve, a healthcare management company that has been implementing value-based care in South Africa for more than a decade, rising premiums and shrinking benefits are symptoms, not causes. The real problem is structural: the industry has been operating as a passive payer when it should be commissioning a better functioning healthcare system.

“The conversation we keep having – about contribution levels, affordability, and who is to blame – is only half the conversation,” says Kasapato. “What is missing is the question of why costs keep escalating and what schemes are actively doing about it.

The World Health Organisation is clear on what that answer should look like: schemes purchasing value for their members, managing the quality and cost of care, and correcting the incentives that keep a poorly functioning system in place. “Until that happens, we will be back here next year, at a higher number, with the same grievances,” she says.

South Africa’s healthcare system rewards providers for the volume of services delivered, not patient outcomes achieved; “More tests, more procedures, more bed days: each generates revenue regardless of clinical necessity. The Health Market Inquiry identified this as a structural failing – schemes, unable to control what providers charge, absorb the pressure by eroding the benefits members thought they were paying for,” says Kasapato.

On average, schemes are currently spending three cents more for every rand they collect; “Even the best-capitalised ones are drawing down their historical reserves. Without meaningful intervention, that gap does not close on its own – it widens. And yet the industry continues to treat this as a pricing problem rather than the systemic one it actually is,” she says.

PPO Serve’s The Value Care Team programme, implemented in partnership with the Government Employees Medical Scheme (GEMS), demonstrates what a different approach looks like in practice. The programme segments members by clinical need – from high-risk complex cases to those currently healthy – and aligns care accordingly. GPs are equipped with real-time data, including visibility of planned admissions from other providers, enabling early intervention before costs escalate. Clinicians are rewarded for measurable patient outcomes rather than the volume of services delivered.

“When patients are well-managed at primary care level, unnecessary hospital admissions fall – and that is exactly what we are seeing,” says Kasapato. “Early pilot data shows a 29% reduction in hospitalisations over three years.  Those savings can then be reinvested into better care. That is what purchasing value looks like in practice.”

For lower-income members, who have historically faced benefit structures favouring hospital care over preventative and primary care, The Value Care Team operates outside discretionary benefit allocations. This preserves out-of-hospital benefits while ensuring members receive coordinated care throughout the year.

“The evidence is already there, globally and in our own programme: investing in primary healthcare costs more today but far less tomorrow. A scheme that cannot absorb the short-term cost of prevention will not survive the long-term cost of inaction. Medical schemes have an enormous amount of power to change the trajectory of healthcare in this country – but only if they are willing to use it. At PPO Serve, we are not waiting for the system to fix itself – we are doing the work,” says Kasapato.

Categories : Medical IndustryTags :

Opinion Piece: Medical Aid Out-of-pocket Healthcare Expenses are the Highest Ever

On By ModernMedia

14 April 2026

Photo by Towfiqu barbhuiya on Unsplash

By James White, Director: Sales and Marketing at Turnberry Management Risk Solutions

Many South Africans assume that belonging to a medical scheme means their hospital treatment will be fully covered. In practice, this is often not the case. Patients are increasingly encountering co-payments, specialist shortfalls and benefit sub-limits that leave them responsible for part of the bill. This happens because medical schemes pay according to their own tariff structures, while specialists often charge significantly more than those tariffs, sometimes as much as 500% of the scheme rate.

The difference between the scheme tariff and the provider’s invoice is then billed to the patient, and it can amount to tens of thousands of Rands. Gap cover exists specifically to address these shortfalls by covering the gap between what medical schemes pay and what healthcare providers charge, offering peace of mind and greater financial certainty.

Healthcare costs are rising faster than household incomes

Medical inflation in South Africa has consistently outpaced general inflation. While many employees receive annual increases of around four or five percent, healthcare costs often rise by nine or ten percent. Hospital tariffs, specialist fees and the cost of advanced medical technology continue to increase each year.

Medical schemes therefore face a difficult balancing act: keeping contributions affordable while managing rising provider costs. To do this, schemes increasingly rely on co-payments, tighter benefit limits and reimbursement based on scheme tariffs. For members, this means that belonging to a medical scheme does not always guarantee that every medical expense will be fully covered.

The shortfall between tariffs and specialist fees

One of the most common out-of-pocket expenses occurs when a healthcare provider charges more than the scheme rate. Medical schemes reimburse treatment according to their own tariffs, while specialists may charge several times that amount. This can create confusion for members, because policies often state that they pay “100% of the scheme rate”. In practice, this means the scheme pays up to its tariff limit, not the full amount charged by the provider.

From a gap cover perspective, this tariff shortfall accounts for the majority of claims. In many cases it represents roughly 78% to 80% of claims, making it one of the most common funding gaps patients experience.

Co-payments and sub-limits add further pressure

Shortfalls are not the only challenge patients face – medical schemes increasingly rely on co-payments and sub-limits to manage rising healthcare costs.

A co-payment is a fixed amount that the member must pay before treatment takes place. Depending on the procedure and scheme rules, these amounts can range from around R5,000 up to R30,000, and in some cases even higher. For many households, being asked to produce this amount upfront can create significant financial strain.

Sub-limits can create a similar problem. Even when a procedure is covered, schemes may limit how much they will pay for certain treatments, scans or specialist services. Once the limit is reached, the remaining cost falls to the patient.

Why adviser education matters

Because the system is complex, many clients only discover these gaps when they receive a bill after treatment. They assume their medical aid will cover the full cost of care, only to find that co-payments, benefit limits or specialist shortfalls still apply.

This is why it is important for advisers to explain clearly how medical schemes pay claims, particularly the difference between scheme tariffs and provider fees. When clients understand how these shortfalls arise, the role of gap cover becomes easier to understand. Rather than being seen as an optional extra, gap cover becomes part of the overall structure of healthcare cover alongside medical aid.

Understanding your healthcare cover before you need it

Healthcare funding in South Africa is unlikely to become less complex in the near future. As costs continue to rise, it is essential to understand how your medical scheme operates and where potential shortfalls may arise.

Many people only learn how their cover works when a claim is processed and an unexpected bill appears. Understanding the difference between scheme tariffs, provider fees, co-payments and benefit limits can help prevent these surprises.

Gap cover plays an important role in addressing these shortfalls by covering the difference between what medical schemes pay and what healthcare providers charge. Speak to a broker about what your medical aid covers, where shortfalls may occur, and how gap cover can help protect you from unexpected medical bills.

Turnberry Management Risk Solutions (Pty) Ltd is an authorised Financial Services Provider (FSP no. 36571). Underwritten by Lombard Insurance Company, an Authorised Financial Services Provider (FSP 1596) and Insurer conducting non-life insurance business.

Categories : Healthcare Politics and RegulationsTags :

University of Pretoria Study Exposes Harmful Impact of Medical Aid Forensic Audits on Physiotherapists

On By ModernMedia

A University of Pretoria study has revealed troubling ethical and procedural gaps in the way medical schemes conduct forensic audits of physiotherapists, showing how practices intended to prevent billing irregularities are often leaving practitioners fearful, stigmatised and traumatised without proving guilt.

Audits of healthcare professionals are designed to detect billing irregularities and protect medical scheme funds. However, research conducted by Lesley Meyer, an extra-ordinary lecturer at University of Pretoria’s Department of Physiotherapy, explored the lived experiences of physiotherapists who have undergone such audits, and found that the audit practices conducted were experienced as punitive and harmful to practitioners rather than corrective.

Forensic audits in the healthcare sector are, in principle, supposed to protect medical scheme funds and by extension, patients’ contributions. In practice, however, Meyer’s research study, published in the latest edition of The South African Journal of Physiotherapy, found that these audits often extend beyond their legal scope and adversely affect the profession, while pocketing patient’s savings instead of returning these funds to the patients in accordance with the Medical Schemes Act.

Under Section 59(3) of the Medical Schemes Act of 1998, schemes may investigate inconsistencies in claims, but when alleged fraud, waste or abuse exceeds R100 000, the matter should be referred to the Health Professions Council of South Africa (HPCSA) or the South African Police Service. However, the study found that schemes mistrust these authorities, so they bypass that requirement by reclassifying potential fraud as administrative billing errors. This practice allows them to conduct internal investigations without external oversight, creating a loophole that has opened the door to misuse, coercive practices and a lack of accountability.“

Participants reported feeling unfairly targeted and singled out, describing the audit process as unfairly conducted. Many felt they were subjected to a witch hunt,” Meyer says, who is also a physiotherapist and runs a private outpatient practice with a special interest in chronic pain and trauma management. Participants described being treated as suspects rather than professionals and reported severe distress caused by a process that offers no transparency or recourse.

The study found that the problem is exacerbated by South Africa’s outdated billing system. The gazetted tariff codes, last updated by the Competition Commission in 2006, have remained unchanged. Due to the fact that medical aid schemes don’t accept new, unlisted codes, practitioners are forced to use outdated tariffs to describe modern, evidence-based treatments. In some instances, practitioners leave those treatments unbilled altogether.

The study found that practitioners were sometimes accused of overbilling or coding errors without being given access to the evidence used against them. Some described being pressured to sign an Admission of Debt (AOD) to avoid escalation, leading to payments that varied from R54 000 in a solo practice to R4,5 million for one group practice.

As reported in the study, the investigators’ tactics were perceived as coercive and participants were forced to either sign AODs or face continued blockages on payments, effectively turning them into cash practices. Physiotherapists operating as cash-based practices were blacklisted because scheme administrators could not use offset controls to manage claims.

Meyer explains: “For those who sign the AOD it means they’re admitting that they’re guilty, which is against the Health Professions Act, because if you are guilty, it means you’ve committed fraud, and you can lose your licence. But participants felt like they didn’t have a choice, because they weren’t getting any money from the schemes.”

The impact on clinical care

One of the key problems highlighted in the research is the lack of external oversight over medical schemes’ auditing procedures. While the Health Professions Council of South Africa regulates practitioner conduct, schemes are governed by the Council for Medical Schemes (CMS), however, a physiotherapist who participated in the study, who complained to the CMS received no response. This gap leaves practitioners vulnerable to arbitrary decisions and offers no appeal mechanism when they believe they have been treated unfairly.

Meyer says the distress caused by the audits has clear hallmarks of trauma with participants describing the trauma they experience being akin to post-traumatic stress disorder, triggering physical reactions such as going into a cold sweat when encountering reminders of the medical fund and enduring stigma from being blacklisted.

One participant said: “Seven months of watching my father die was easier than this experience.

”Meyer’s research shows that these experiences aren’t isolated incidents but systemic. Interviews revealed a pattern of practitioners who felt coerced into compliance due to their fear of professional ruin.

The study revealed that physiotherapists perceived the audit process as vindictive rather than beneficial. The physiotherapists also felt that the forensic investigators perceived them as being guilty from the start, without considering alternative reasons for irregular billing patterns.

These hostile auditing processes contradict the principle of procedural fairness, Meyer says, which requires fair treatment, transparency, impartiality and an opportunity to be heard.The way forwardThe study recommends teaching undergraduate and registered physiotherapists about forensic literacy. Therefore, Meyer created five lectures based on her findings’ which have been implemented with the fourth-year physiotherapy students as part of the IHL module at the University of Pretoria, to empower students and increase their resilience when faced with forensic audits in private practice.

Moreover, the study recommends a framework that allows practitioners to be heard and protected while ensuring that accountability remains central. Such a framework includes establishing an independent oversight body, standardising investigative procedures and ensuring audited practitioners can access evidence, respond to allegations and appeal decisions. Meyer will continue with this framework through a PhD.

A significant development since Meyer’s study was completed, is the release of the final report by an independent legal panel that reviewed how Section 59(3) of the Medical Schemes Act is applied in forensic audits of healthcare professionals. Meyer says the report confirmed many of the issues raised in her research, including retrospective audits, a lack of transparency and potential misuse of power by medical schemes.“

The release of this report is an important step toward institutional accountability and reform,” Meyer says. “However, the full implementation of its recommendations remains critical to ensure fair audit practices and to restore trust among healthcare providers.”

“The people I interviewed were not trying to avoid accountability. They wanted fairness. They wanted to be heard. If we don’t address the lack of oversight, we risk losing good practitioners and damaging trust in the healthcare system itself.”

Read the full study here

Categories : Medical IndustryTags :

Bonitas Medical Fund Revitalises Future of Healthcare in SA with New Strategic Partners

On By ModernMedia
Photo by Sora Shimazaki

The healthcare industry has evolved significantly in the past decade with innovation, improved servicing and consolidation of medical schemes emerging. Bonitas Medical Fund has taken a strategic step in responding to the needs of its members and the Health Citizens of South Africa, by appointing Momentum Health as its new administrator from 1 June 2026.

With a considerable history spanning over 4 decades, Bonitas Medical Fund has emerged as one of the leaders in the medical scheme market. Covering over 750 000 lives, the Scheme is known as the medical aid for South Africa with a range of options – strategically designed to meet the needs of South Africans from all walks of life.

The change in administration is in line with the guidelines of the Health Market Inquiry and the industry Regulator, the Council for Medical Schemes (CMS). In 2024, the CMS stated that, “one of the main issues driving market stagnation is the prevalence of ‘evergreen’ contracts”. This alludes to long-term agreements between medical schemes and suppliers spanning decades without being subject to regular competitive procurement processes.

Principal Officer, Lee Callakoppen, explains, “One of our key strategic objectives is to ensure we create value for our members and key stakeholders. This can take the form of benefit optimisation, favourable tariff negotiations, amalgamations to obtain critical mass or optimised service. The healthcare industry has evolved considerably over the past decade, and it was critical for the Scheme to evolve in line with this. Over the past 48 months, the Board have extensively debated the steps needed to be taken to place Bonitas in a competitive position and ensure that it remains sustainable in the best interest of our members. In doing so we have continuously evaluated the value provided by our service providers with consideration to our strategic objectives and the capabilities of our service providers as well as the expectations of our members corporate clients, healthcare professionals, and brokers. We have seen medical schemes placed under financial strain with sustainability challenges emerging and we remain committed to remaining relevant to our members and must therefore be vigilant in our approach.”

This was followed by rigorous ongoing benchmarking exercises and a subsequent Request for Proposal process for administrative services and managed care – with Momentum Health appointed as the successful entity for the provision of administration services and Private Health Administrators appointed to provide managed care services.

“We are delighted to cement this relationship with Momentum Health, who have demonstrated that they have the necessary capabilities to exceed expectations and support us in our strategic growth objectives” Callakoppen said. “Bonitas’ performance in the past 18 months, has exceeded all previous benchmarks with over 80 000 new families successfully enrolled on the Scheme and financial sustainability stronger than previous years. We see these appointments as strategic enablers to challenge the status quo – and drive value optimisation to continue leading the healthcare industry. Our aim is to optimise efficiencies, achieve mass enrolment, and meaningfully contribute to the shaping of private healthcare in South Africa.”

Hannes Viljoen, Chief Executive Officer of Momentum Health welcomed the appointment, citing it as a key strategic opportunity in the dynamic open market for Momentum Health. “We are excited about positively impacting the health of more people. The group currently service over 3,3 million beneficiaries in Africa and more than 25 million world-wide and are strategically and operationally positioned to deliver value in a meaningful and impactful way,” he said.

Dr Ayanda Mbuli, Chief Executive Officer of PHA, was pleased with the outcome, “We are deeply honoured by Bonitas’ decision to entrust PHA with its managed healthcare function, a historic milestone for the Scheme. This partnership presents a unique opportunity to further optimise the care received by Bonitas members and to meaningfully contribute to both the Bonitas healthcare agenda and the broader South African health landscape.”

Bonitas has been a leading open scheme in South Africa for several decades and these changes will open opportunities to build a more significant and influential open scheme that caters for more South African’s health care needs.

Categories : Expert Opinion Medical IndustryTags :

The Making of South Africa’s Medical Aid Crisis

On By ModernMedia

As of this month, South African medical aid scheme contributions have increased by between 6–9% – nearly triple the Council for Medical Schemes’ recommended 3.3% guideline. While lower than last year’s double-digit surge, the underlying problem remains: premiums keep climbing while benefit coverage keeps shrinking, exposing cracks in private healthcare that are becoming impossible to ignore.

“We’re watching private healthcare price ordinary South Africans out of the market, one annual increase at a time,” says Lungile Kasapato, CEO of PPO Serve, a healthcare management company that has been implementing value-based care in South Africa for more than a decade. “Medical schemes are caught in an impossible position – unable to control what providers charge, they’re left managing what they cover. The result is diminishing benefits, rising co-payments, and mounting out-of-pocket costs for members.”

The root of the problem lies in how healthcare is paid for. Fee-for-service, the dominant reimbursement model, rewards volume over outcomes. More tests, more procedures, more bed days – each generates revenue regardless of whether they actually improve patient health. This narrow focus fragments care and drives costs up while keeping value low.

“No amount of funding can fix a payment model that drives the wrong incentives,” Kasapato explains. “Real change requires rethinking not just what we pay for, but how we pay for it.”

Value-based care offers a fundamentally different approach: putting patients at the centre, rewarding proactive care, and linking payment directly to health outcomes. PPO Serve’s The Value Care Team demonstrates what this looks like in practice. GP-led multidisciplinary teams receive monthly, risk-adjusted payments based on patient complexity, supporting holistic care and linking meaningful incentives to measurable results. Rather than maximising billable services, providers focus on optimising patients’ overall health.

For members, this means care is no longer limited by rigid benefit caps or pre-authorisation hurdles, but structured around what genuinely enhances the efficient delivery of their care. A dedicated care coordinator guides patients through decisions made collaboratively by their GP and allied health professionals, with each team member sharing accountability for better outcomes.

But scaling models like this requires medical schemes and public funders to step up. “The challenge isn’t proving value-based care works – it’s embedding it in an infrastructure built for an entirely different system,” says Kasapato. “Claims processing, scheme administration, provider networks – every layer of private healthcare is designed with fee-for-service in mind. Transitioning to outcome-based payment means rebuilding that system and accepting the upfront investment and friction that comes with structural change. The alternative is stark: a private healthcare market that collapses under its own cost pressures, pricing out members faster than schemes can adjust. South Africa is already on that trajectory.”

“If we’re serious about universal health coverage and the long-term sustainability of the private sector, we can’t keep treating symptoms while ignoring causes,” says Kasapato. “Value-based care models are already demonstrating what’s possible. The question isn’t whether transformation is worth the investment – it’s whether we can afford to delay it any longer. The more organisations that embrace a strategic purchasing role, the greater the potential for meaningful change, not just for medical schemes but for South Africa’s healthcare system and the millions who rely on it.”