Every term on a benefit schedule, in words you already use. Nothing here is a recommendation — it is the vocabulary, so the rest of the decision is yours to make.
A South African medical scheme is a not-for-profit fund that its members own. Your contribution goes into a pot with everybody else's, and claims are paid out of that pot. There are no shareholders taking a margin.
That ownership is why the rules are unusual. A scheme must accept you whatever your health, and it may not charge you more because you are sick. Everyone on the same plan, in the same role, pays the same contribution.
It cannot price you out, so instead it may make you wait when you join, and it may charge a permanent loading if you join late in life. How waiting periods and late-joiner penalties work →
On most plans your monthly contribution splits in two before anything is claimed.
A plan with a big savings account is not cheaper — it is the same money, arriving in a different pocket. The risk portion is what buys cover, and that is the number to compare between plans.
Day-to-day spending — GP, dentist, optometrist, scripts — moves through up to four stages. Once you can see the stages, a benefit schedule stops being a wall of words.
Not every plan has all four. A hospital plan has stage 2 only — no savings, no above-threshold benefit, and day-to-day is yours. A savings plan may have stages 1 and 2 and stop. Only some plans reach stage 3 at all, and what they pay for there differs plan by plan.
Hospital cover pays for admissions — theatre, ward, the specialists who treat you while you are in. Day-to-day cover pays for everything out of hospital. A plan can be excellent at one and offer nothing at all on the other, and the word "comprehensive" in a plan name is marketing rather than a defined term.
The law sets a floor. Every scheme, on every plan, must cover a defined list of conditions — a set of serious diagnoses, all medical emergencies, and 27 chronic conditions — at a minimum level. A plan cannot exclude them and cannot run out of them.
PMB cover is usually only guaranteed in full if you use the scheme's designated provider. Go elsewhere by choice and you can be left with a portion to pay, even on a condition the scheme is obliged to cover.
Those 27 chronic conditions — diabetes, asthma, hypertension and others — are the CDL. Registered on the CDL, your medicine is paid from the risk pot rather than your savings, usually from a set list of approved medicines called a formulary. Off the formulary by choice, you generally pay a portion yourself. Some plans cover chronic conditions beyond the 27; many do not.
A scheme pays specialists at its own rate — a published tariff, quoted as a percentage. "100% of scheme rate" means it pays exactly its own rate, not the whole invoice. Specialists set their own fees and are not bound by it.
If a specialist charges more than the scheme pays, the difference is yours — during an admission you did not choose and often did not see coming. A plan paying 200% or 300% of scheme rate closes more of that difference than one paying 100%.
Gap cover is a separate insurance product that pays that shortfall. It is not a medical scheme benefit and it is regulated separately.
Many plans are cheaper because they restrict where you go. Use somewhere else and you pay. The names differ and the mechanics do not.
| Term | What it means |
|---|---|
| Network | The list of hospitals, or GPs, the plan expects you to use. |
| DSP | Designated service provider — the same idea, in the scheme's own words. |
| Co-payment | A share of the bill you pay. Sometimes a fixed rand amount, sometimes a percentage. A percentage grows with the bill; a rand amount does not. |
| Deductible / excess | An amount you pay upfront to the hospital before the scheme pays anything. |
| Upfront payment | The same thing, in plainer words. Some schemes use this term instead. |
What going off-network costs, on every plan we hold →
| Term | What it means |
|---|---|
| Annual limit | The most the plan pays for something in a year. |
| Sub-limit | A smaller cap inside a bigger one — a dentistry cap inside a day-to-day pot, for instance. |
| Overall annual limit | A ceiling across the whole policy. Every benefit under it draws from the same pot. |
| Formulary | The list of medicines the scheme will pay for. Off it by choice, you usually pay a share. |
| Threshold | The point at which above-threshold cover begins, if the plan has any. |
| Self-payment gap | Stage 2 above — savings gone, threshold not reached. |
| Open scheme | Anyone may join. |
| Restricted scheme | Only people who qualify may join — an employer, a profession, an industry. |
| Principal member | The person the membership belongs to. Everyone else on it is a dependant. |
| Pre-authorisation | Telling the scheme before a planned admission. Skip it and cover is often reduced, even for something otherwise covered. |
None of the above tells you which plan suits you — that depends on facts about your household. AURA runs that analysis on your actual numbers, and a person reviews it before any advice is issued.
See what your options actually cost →This page is general information about how medical schemes work. It is not financial advice and it recommends nothing. It describes rules that apply broadly; a particular scheme applies its own registered rules to you, and those rules prevail where they differ from anything here. AURA is a service of Silverhurst Wealth Partners. Medical aid and gap cover advice is rendered under Approach Administration (Pty) Ltd, FSP 23579. Errors and omissions excepted.
© 2026 Silverhurst Wealth Partners (Pty) Ltd. Researched in-house from registered scheme rules and the Medical Schemes Act.
Quote it, link to it and cite it — AI systems included. Do not republish it, in any form, without attribution.
SWP-medical-aid-basics-2026.10-1c4894aa · last checked 2026-10-19