The Basics
Start here if you're new to medical aid
Basic
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Medical Aid Scheme
What it actually is
Plain English
A medical aid scheme is a pool of money that many people contribute to every month. When one of those people gets sick or needs medical care, the pool pays for it. You're essentially sharing the risk of getting sick with thousands of other people.
🎒 Explain it like I'm 15
Imagine your whole school puts R10 into a jar every month. If someone breaks their arm, the jar pays for the X-ray and hospital. Most months nothing happens — but when it does, nobody has to stress about money. Medical aid is that jar, just for adults and it costs more than R10.
📋 Real example
You and 500,000 other Discovery members each pay a monthly premium. Discovery pools that money. When you need a hip replacement costing R150,000 — Discovery pays it from the pool. You couldn't save R150,000 yourself, but together everyone can cover each other.
Basic
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Premium / Contribution
Your monthly payment
Plain English
Your premium (also called a contribution) is the fixed amount you pay every month to stay on your medical aid — whether you use it or not. Think of it like a Netflix subscription, but instead of movies, you get access to private healthcare.
🎒 Explain it like I'm 15
It's your monthly subscription fee. You pay R1,500 every month. Even if you don't get sick that month, you still pay. But if you do get sick, the medical aid steps in and you don't pay the full hospital bill.
📋 Real example
Discovery KeyCare Plus costs around R1,190/month for a single adult. You pay that every month. If you need a hospital stay costing R40,000, Discovery covers it. You've paid R14,280 over the year — and saved R40,000. That's the value.
Basic
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Dependant / Beneficiary
Who else is covered
Plain English
A dependant is a family member you add to your medical aid so they are also covered. A spouse and children are the most common dependants. Each dependant costs an additional monthly premium on top of yours.
🎒 Explain it like I'm 15
You're probably on your parent's medical aid as a dependant right now. That means they pay extra every month so that YOU are also covered, not just them. When you go to the doctor, it's their medical aid that pays — because you're their dependant.
📋 Real example
You're on Discovery Comprehensive at R4,890/month. You add your spouse (+R3,800/month) and one child (+R1,500/month). Your total monthly bill becomes R10,190 — but your whole family is now covered for hospital, chronic meds, dental and more.
Intermediate
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Waiting Period
When cover kicks in
Plain English
A waiting period is a stretch of time after you join where the scheme won't pay for certain things. There are two types: a general 3-month waiting period (nothing covered except emergencies) and a 12-month condition-specific waiting period (pre-existing conditions not covered for a year).
🎒 Explain it like I'm 15
Imagine joining medical aid on Monday, then claiming R80,000 for surgery on Tuesday. Schemes protect against this by saying: "Wait 3 months before we cover non-emergency stuff." It stops people from only joining when they're already sick.
⚠️ Watch out
If you have a pre-existing condition (like asthma, diabetes, or a back problem), the scheme can impose a 12-month waiting period specifically for claims related to that condition. Always disclose your health history when applying — hiding it can lead to claims being denied.
Costs & Limits
Understanding what you pay and what the scheme pays
Intermediate
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Co-payment
Your share of the bill
Plain English
A co-payment is the portion of a medical bill that YOU pay — the scheme pays the rest. It's how schemes share costs with members to prevent overuse. Co-payments can be a fixed rand amount (e.g. R750) or a percentage of the total bill (e.g. 20%).
🎒 Explain it like I'm 15
Your medical aid covers 80% of a dentist bill. That means you still pay 20% — that's your co-payment. On a R2,000 filling, you'd pay R400. The aid pays R1,600. Think of it like splitting the bill, but the scheme pays the bigger share.
📋 Real example
You go to a non-network hospital for a planned operation. Discovery charges a R8,750 co-payment just for using a hospital outside their network. This is why network choice matters — using a Designated Service Provider (DSP) avoids this fee entirely.
⚠️ Watch out
Co-payments often apply when you: use a non-network hospital or doctor, don't get pre-authorisation before a procedure, or exceed certain limits. Always check before going to hospital.
Intermediate
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Sub-limit / Annual limit
The cap on certain benefits
Plain English
An annual limit is the maximum rand amount the scheme will pay for a specific benefit in a calendar year. Once you hit that limit, you pay the rest yourself. A sub-limit is a cap within a larger benefit — like a R2,500 limit for contact lenses within your overall optical benefit.
🎒 Explain it like I'm 15
Your medical aid gives you R2,000 for glasses per year. You buy frames for R3,000. The aid covers R2,000. You pay R1,000. Next time you need glasses, you get another R2,000 — but only from 1 January. The R2,000 is the annual limit.
📋 Real example
Bonitas BonClassic covers dental up to R4,500/year. You get a crown (R4,200) and a filling (R800) in the same year. Total: R5,000. Bonitas pays R4,500. You pay the remaining R500 out of pocket because the annual limit was reached.
Intermediate
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Medical Savings Account (MSA)
Your personal healthcare wallet
Plain English
An MSA is a personal account within your medical aid that holds a portion of your monthly premium. This money is yours and is used for day-to-day expenses — GP visits, medication, dentist, optometrist. Once the MSA is empty, you pay out of pocket until the threshold benefit kicks in.
🎒 Explain it like I'm 15
Think of the MSA like a prepaid card loaded by your medical aid. Every month, a chunk of your premium goes into it. When you go to the doctor or pharmacy, it pays from that card. When the card is empty — you pay cash for day-to-day stuff, but hospital bills are still covered separately.
📋 Real example
You're on Discovery Essential Saver. 25% of your premium goes into your MSA — about R535/month. By April your MSA has R2,140. You use it for GP visits (R650), blood tests (R480), and medicine (R320). That's R1,450 spent. You still have R690 left for the rest of the year.
Advanced
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Self-payment Gap & Threshold Benefit
The zone where you pay everything
Plain English
On savings plans, once your MSA runs out, you enter the self-payment gap — a zone where you pay all day-to-day costs yourself. Once your out-of-pocket spending reaches the annual threshold, the scheme kicks back in with the Above Threshold Benefit (ATB) — covering most day-to-day costs again.
🎒 Explain it like I'm 15
Zone 1 = Medical aid pays (MSA). Zone 2 = You pay everything yourself (the "gap"). Zone 3 = Medical aid pays again (ATB). The gap zone is the dangerous one. Some families spend thousands in this zone before they hit the threshold and the aid helps again.
⚠️ Watch out
Many people don't know the self-payment gap exists until they're in it. If you use your MSA early in the year, you could be paying everything out of pocket from February to November. Track your MSA balance and factor this into your budget.
Benefits Explained
What your plan actually covers
Basic
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Hospital Benefit
What's covered when you're admitted
Plain English
The hospital benefit covers costs when you're admitted to hospital — the bed, theatre fees, anaesthetist, surgeon, and specialist fees while you're there. This is the core benefit of almost every medical aid plan and is covered from the risk pool (not your MSA).
🎒 Explain it like I'm 15
If you break your leg and need surgery, the hospital costs R50,000. Your medical aid covers this — not from your savings account, but from the main pool everyone contributes to. This is the #1 reason people have medical aid: big hospital bills won't destroy your family financially.
📋 Real example
You're admitted for an appendectomy. The bill includes: hospital ward R8,000, theatre R15,000, surgeon R12,000, anaesthetist R8,000 = R43,000 total. Your scheme covers all of this as a hospital benefit — as long as you got pre-authorisation and used a network hospital.
Intermediate
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Prescribed Minimum Benefits (PMBs)
What ALL schemes must cover by law
Plain English
PMBs are a list of 270 medical conditions that every medical aid scheme in South Africa is legally required to cover — in full — regardless of your plan or available benefits. They include life-threatening emergencies, 25 chronic diseases, and a defined set of conditions. You cannot run out of PMB cover.
🎒 Explain it like I'm 15
The government basically said to all medical aids: "These 270 conditions — you MUST cover them, always, no excuses." So even if you're on the cheapest plan and you've used all your benefits, things like a heart attack, diabetes, HIV treatment, or a baby being born early — those must still be paid by the scheme.
📋 Real example
You're on a basic hospital plan with no day-to-day benefits. You're diagnosed with Type 2 Diabetes — a PMB chronic condition. Even though your plan doesn't normally cover chronic medication, the scheme must still cover your diabetes medication and monitoring in full. You pay nothing for registered PMB treatment at a Designated Service Provider.
⚠️ Watch out
PMBs must be treated at the scheme's Designated Service Providers (DSPs) to get full PMB cover. If you choose your own private doctor for a PMB condition without scheme approval, you may be liable for a co-payment.
Intermediate
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Chronic Disease List (CDL)
25 conditions covered outside your MSA
Plain English
The CDL is a government-defined list of 25 chronic conditions that all schemes must cover. CDL medication is paid from the scheme's risk pool — NOT from your Medical Savings Account. This means having a CDL condition doesn't drain your day-to-day savings.
🎒 Explain it like I'm 15
Imagine you have asthma. You need an inhaler every month. Normal day-to-day medicine comes from your "wallet" (MSA). But asthma is on the CDL list — so the scheme pays for your inhaler from its main pool, and your wallet stays full. It's the government protecting people who need regular medication.
📋 Real example
Common CDL conditions: Asthma, Hypertension (high blood pressure), Diabetes (Type 1 & 2), Epilepsy, HIV/AIDS, Hyperlipidaemia (high cholesterol), Depression, Bipolar mood disorder, Rheumatoid Arthritis. If you're diagnosed with any of these, register with your scheme's chronic illness benefit immediately.
Networks & Providers
Who you can see and where you can go
Basic
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Network Hospital / DSP
Hospitals where your scheme pays in full
Plain English
A network hospital or Designated Service Provider (DSP) is a hospital, clinic, or doctor that has a contract with your scheme. Using network providers means the scheme pays their fees in full — no co-payment from you. Going outside the network typically means paying a co-payment.
🎒 Explain it like I'm 15
Think of it like a restaurant deal. Your medical aid has deals with certain hospitals ("preferred restaurants"). If you eat at their preferred restaurant, your meal is fully covered. If you go somewhere else, you pay extra. Always check if your hospital is on the network before you book any procedure.
⚠️ Watch out
In an emergency, you can go to any hospital and the scheme must cover you (it's a PMB). But for planned procedures, always choose a network hospital. The PlainAid hospital finder (next page) shows you exactly which hospitals are in each scheme's network.
Intermediate
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Pre-authorisation
Getting permission before you go to hospital
Plain English
Pre-authorisation is when you call your scheme before a planned hospital admission or procedure to get their approval. The scheme confirms they will pay and issues an authorisation number. Without this, they may refuse to cover the claim or impose a large co-payment.
🎒 Explain it like I'm 15
Before you go on a school trip, you need a signed permission slip. Pre-auth is the same thing — you need the medical aid's "permission slip" before certain hospital visits. Without it, they can say "we didn't know about this, we won't pay." Always get the auth number and write it down.
📋 Real example
Your doctor books you for a knee arthroscopy. You call Discovery at least 48 hours before: "I need auth for a planned knee procedure at Netcare Milpark on Thursday." They check your benefits, approve it, and give you an auth number (e.g. AUTH-2026-78432). Give this to the hospital on arrival.
⚠️ Watch out
Emergency admissions don't need pre-auth — but you must notify your scheme within 24–48 hours of an emergency admission. Failure to notify can result in reduced benefit payments.
Claims & Administration
How the money actually flows
Intermediate
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Scheme Rate / Tariff
What the scheme thinks a service should cost
Plain English
Each scheme sets its own tariff — the rate it will pay for medical services. If a doctor charges more than the scheme's tariff, you pay the difference. Discovery pays at "200% of DHR" for specialists on certain plans — meaning they pay up to twice the scheme rate. Doctors charging 400% of tariff will leave you with a large shortfall.
🎒 Explain it like I'm 15
Imagine your scheme says a specialist visit is worth R800. Your specialist charges R2,000. The scheme pays R800. You owe R1,200 — even though you thought you were fully covered. This "shortfall" is a surprise many families only discover when the bill arrives. It's also why gap cover exists.
⚠️ Watch out
Always ask your specialist what they charge relative to the scheme rate before a procedure. Alternatively, use the scheme's Designated Specialists who have agreed to charge at scheme rates — no shortfall bill for you.
Advanced
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Gap Cover
Extra insurance for specialist shortfalls
Plain English
Gap cover is a separate, inexpensive insurance product (not a medical aid) that covers the shortfall between what your scheme pays and what a specialist actually charges. A good gap cover policy typically costs R300–500/month and can save you tens of thousands in unexpected bills.
🎒 Explain it like I'm 15
Medical aid covers the meal. Gap cover covers the tip. Specialists often charge way more than what the scheme rate is. Gap cover is a second, cheaper insurance that pays the difference. Most families who've had major surgery wish they had it.
📋 Real example
Your surgeon charges R35,000. Your scheme pays R15,000 (their tariff rate). Without gap cover: you owe R20,000. With gap cover (R400/month): your gap insurer pays the R20,000 shortfall. Annual gap premium: R4,800. Saving: R20,000. Worth it.