Your annual medical aid review: what to check before committing for another year

Published by MedXpert, a service of Optivest Health Services (Pty) Ltd, FSP 13475 | Last updated: 12 October 2026

That is the short answer. The longer one matters because only one of the three decisions touches your waiting periods. This page covers what drives your increase, what changes when you move, and five checks to run first.

The three decisions, and the deadline

Your scheme sends you two things each year: a new contribution and revised benefits, both effective 1 January, unless otherwise specified.

1. Stay on your current option at the new contribution.
2. Change option within your current scheme.
3. Change scheme entirely.

The Medical Schemes Act 131 of 1998 provides a general guideline of when benefit review related changes should be made and finalised, but it’s your scheme that decides the specific timeline. Most windows open around mid-October and close between late November and early December, though a few run to 31 December. Regulation 4(3) also allows a scheme’s rules to limit option changes to 1 January and to require at least three months’ written notice, so check your own scheme’s rules.

Why does my medical aid contribution go up every year?

There are several factors that determine the increase, but it can be narrowed down to four main points.

• The cost of care. Private hospital costs, practitioner tariffs and medicine prices have risen faster than general inflation in most recent years.
• How the option performed. Section 33(2) of the Act requires every benefit option to be self-supporting in terms of membership and financial performance, and Regulation 29 requires reserves of at least 25% of gross annual contribution income. An option paying out more than it collects must correct that.
• Your own household. Under Section 29(1)(n), contributions may be differentiated only on income and the number of dependants. For example, you have a principal member, an adult dependant and a child dependant in 2026. In 2027, the child dependant will celebrate the birthday that will make them an adult dependant. Now you are paying a principal member rate and the rate of two adult dependants because the child premium no longer applies.
• The Consumer Price Index. Circular 20 of 2026 published by the Council for Medical Schemes sets forth a guideline for medical schemes for their benefit and contribution increases and in this document, they address CPI. The CMS uses CPI as a proxy measure for assessing the affordability of contribution increases and estimating price inflation in the private healthcare sector. According to the South African Reserve Bank, headline inflation is expected to average 3.8% in 2027.

What is within your control is short: your registered dependants, the income band on the scheme’s records, and the option you are on. The rest is decided before the letter reaches you.

Should I change my medical aid option?

Five checks do most of the work, and each needs nothing but your scheme’s own information.

Check 1. Did your medical savings account run out, and in which month?

A medical savings account (MSA) that empties in July tells you something different from one that empties in November. The month matters more than the balance.

Check 2. Did you pay out of pocket for something you expected to be covered?

Find out why before deciding anything. A benefit limit, a sub-limit, a network rule and an exclusion are four different problems, and each should be analysed holistically with the help of a specialist before you decide to change options.

Check 3. Are your providers still in network for next year?

Network arrangements are renegotiated annually, and if your designated service provider or hospital isn’t on the list anymore then there’s a good chance you’ll experience penalty co-payments for using a non-network provider. Only network providers have arrangements with your scheme to charge lower rates, so using a service provider outside your network will also result in shortfall payments.

Check 4. Is everyone’s chronic medicine still on the formulary?

Check each item against the formulary for the option you will be on in January. If your medication has been removed then check if a generic will be covered. Purchasing medication that’s no longer on the formulary will either result in a co-payment or it won’t be covered at all.

Check 5. Has your household changed, or is it about to?

A new dependant, a chronic diagnosis, a planned procedure or a move to an area with different providers all change what matters. So does your income band, but only if you’re on an income-based option.

What happens to my waiting periods if I change option?

Section 29A of the Act deals with waiting periods imposed on admission as a member or dependant of a scheme. Moving between options inside a scheme you already belong to is not an admission, so it does not apply. What applies instead is your scheme’s rules on when a change is permitted.

Benefits are separate. A different option can carry different limits, networks and formularies from day one. Our guide to medical aid waiting periods covers the joining and switching scenarios in full.

What changes if I move to a different scheme?

Waiting periods. With more than 24 months of uninterrupted cover, and joining within 90 days since your previous cover came to an end, Section 29A allows a general waiting period of up to three months, but Prescribed Minimum Benefits will be covered. In this scenario, you will not have a 12-month condition-specific waiting period. If you have less than 24 months of uninterrupted cover or if you haven’t had cover for more than 90 days, then other underwriting rules will apply. Always consider the implications of underwriting before changing schemes or cancelling your cover.

Late joiner penalties. Regulation 13 allows a penalty on the contribution of an applicant aged 35 or older, if that applicant has gaps in creditable coverage. The bands are 5%, 25%, 50% and 75%, and the appropriate penalty will be assigned based on the number of years an applicant has gone without cover. The calculated penalty will apply to the portion of the contribution relating to the person that the penalty is allocated to. Our page on the late joiner penalty works through the calculation.

Upgrade, downgrade or stay

How did you actually use your cover this year?

Four things to pull from your scheme before deciding anything. All are available on request.

1. Total contributions paid this year.
2. Total claims paid for you and from where in your plan it was paid (e.g., your savings or the risk pool).
3. The month your day-to-day or savings benefit ran out, if it did.
4. Every claim rejected or paid short, with the reason given for each.

What should my broker be doing at review time?

Reading your scheme’s annual communication, checking it against how your household used its cover, and lodging any change in writing before the deadline.

“Most people can tell us to the rand what they pay,” says Lincoln O’Ehley, General Manager at MedQuote. “Very few can tell us what they claimed, which month their day-to-day funds ran out, or whether their chronic medication is on next year’s formulary. Those three answers are pertinent to your decision-making process for your review.”

MedXpert is part of Optivest Health Services, which has advised South African consumers for 26 years and is contracted with most major open schemes. If you would like someone to run the five checks with you before your deadline, send your details and we will call you back. The call is free and there is no obligation.

Frequently asked questions

MedXpert is an independent medical scheme advisory service and part of Optivest Health Services (Pty) Ltd, an authorised Financial Services Provider, FSP 13475. MedXpert is not a medical scheme. This article is general information about how medical scheme rules work in South Africa and is not advice about any specific scheme or benefit option.