Here’s what you need to consider before making medical scheme choices for 2025

There are important factors to keep in mind when you make your medical scheme choices for next year, although it is difficult to keep up with the ever-increasing premiums that seem to be very high for 2025.

As living costs surge, healthcare coverage can feel like a luxury, particularly for young, healthy South Africans. However, with policy debates on National Health Insurance (NHI) and private healthcare, medical scheme membership remains essential and offers crucial protection against unpredictable medical costs, Dr Rajesh Patel, head of health system strengthening at the Board of Healthcare Funders (BHF), says.

Medical scheme members are feeling the strain of recent premium increases and many of them may be considering downgrading their options or even opting out entirely. However, Patel warns, continuous medical scheme coverage is crucial for maintaining financial security and supporting your long-term health.

Reports from the Council for Medical Schemes (CMS) reveal that South African medical schemes collected R232 billion in premiums and paid over R218 billion in claims for approximately 9 million beneficiaries during the 2023/2024 period.

These funds covered a wide range of healthcare needs, from hospital stays and advanced procedures to life-saving medications.

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This is why your premiums are increasing

Patel identifies these main drivers behind increasing medical scheme premiums:

• Medical inflation and rising healthcare costs: Healthcare costs have consistently increased  faster than general inflation, driven by advancements in medical technology, new treatments and more expensive medications. Medical schemes must adjust premiums to keep pace with these rising costs to ensure adequate coverage for members.
• Increasing prevalence of chronic illnesses: Chronic diseases, such as diabetes, hypertension and heart disease, are on the increase. These conditions require continuous and often costly management, contributing to higher-value claims and increased premiums.
• Deferred costs from Covid-19 relief measures: During the pandemic many medical schemes did not increase premiums to ease members’ financial strain, creating a funding gap. Now medical schemes must fill this gap to maintain financial sustainability and ongoing access to quality healthcare.

Patel says it is still important to stay a member of a medical scheme. “Downgrading or opting out of medical scheme coverage may seem like a quick way to save money, but it can lead to long-term financial risks and higher costs.”

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Why it’s important to stay a medical scheme member

It is important to stay covered because:

• You are protected against high medical costs: Medical expenses can be unpredictable. Emergency care, surgeries and specialist treatments can cost hundreds of thousands of rands. Medical schemes protect members from these high costs, ensuring access to care when you need it most.
• You avoid late-joiner penalties and waiting periods: Members who end their membership and try to rejoin later can face steep late-joiner penalties, increasing your premiums by up to 75%. The Medical Schemes Act of 1998 imposes these penalties to ensure fairness between long-time contributors and late joiners who seek coverage only when health issues arise. Staying covered avoids these penalties and maintains premium affordability.
• Access to preventive and wellness care: Many schemes offer preventative care, including wellness check-ups, screenings and mental health support. Preventative care detects health issues early and lowers the risk of severe complications that are more expensive to treat, making it invaluable for proactive health management and long-term savings.
• Coverage for chronic and unexpected conditions: Medical conditions can develop unexpectedly and at any age. Continuous coverage ensures access to necessary care for chronic as well as acute conditions, including lifestyle-related illnesses such as hypertension and diabetes. Staying on a medical scheme provides consistent access to treatment and management of these conditions.

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How to choose the best medical scheme option

Patel says you should consider these steps if you consider adjustments to your coverage to ensure you select a plan that balances affordability with essential benefits:

• Evaluate your health profile: Assess your current health, family medical history and lifestyle. Healthy individuals may consider plans prioritising preventative care, while those with chronic conditions should choose options covering specialist visits, medication and ongoing treatment.
• Focus on essential coverage: If the premiums are a concern for you, consider plans covering essential hospital and emergency needs. These options provide high-cost protection without extensive extras, keeping premiums manageable while securing critical coverage. A consultation with your scheme or broker can help identify the best options for your budget and health needs.
• Participate in wellness programmes: Many schemes reward healthy lifestyle choices through wellness programmes, offering incentives such as discounts. Engaging in these programmes reduces costs and encourages healthier living, adding financial and personal health benefits.

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Always remember long-term value

You should always keep the long-term value of staying covered in mind, Patel says. “Remaining on a medical scheme is about more than immediate healthcare needs. It is about long-term security for your health as well as your finances. Medical schemes offer peace of mind that, should an emergency arise, you are protected from the high costs of private healthcare.”

He points out that there is a push for affordable, accessible healthcare for all. “With rising healthcare costs, the BHF advocates for improved affordability and accessibility. To this end, it has engaged the Competition Commission to allow collective bargaining between schemes and providers, while urging the CMS to revise costly prescribed minimum benefits (PMBs) to emphasise preventative and primary care.

In addition, Patel says the BHF also calls on the minister of health to implement regulations under the Medical Schemes Act for a more affordable PMB package that will allow low-cost, basic benefit options that would expand medical scheme access and promote healthcare and financial security across the country.