Is your medical aid right for you? Here’s what to consider

At the end of each year, before the festivities of the holiday season kick in, it’s worth taking a moment to pause and consider this important question: is your medical aid plan option still meeting your healthcare needs?

Re-assessing your cover and deciding if your current scheme and plan are adequate to meet your needs for the year ahead is something he recommends that clients do in consultation with their advisers. Here, you should consider your family’s healthcare requirements, taking into account budget, age, and health status to make sure that you’re best protected going into the next year.

Adapting to change

Changes in medical scheme options are common as your life changes. You may need higher cover as your family grows or for more specialised treatment if you’re diagnosed with a chronic disease or critical illness. In addition, if you relocate or ‘semi-grate’ for work or lifestyle reasons, you may need to adjust access based on new hospital networks.

Budget also plays an important role. If you change employment, you may get access to medical fund subsidies, which allow you to upgrade your coverage. On the other hand, budget constraints may mean you need to downgrade your cover. Clients are advised to work with their financial advisers to understand their finances so that they can make the right medical aid choice together.

Importantly, you need to be aware of waiting periods and possible penalty fees if you switch or change your plan. When switching to another medical aid provider, the Medical Scheme Act states that waiting periods may be applied for:

• Individuals who have applied to join a medical scheme but have never belonged to a registered South African medical scheme before.
• Individuals who have had a break of more than three months since ending their membership with their previous medical scheme.
• Individuals who have belonged to a registered South African medical scheme for less than two years and have applied to join another scheme within three months of ending their previous membership.
• Individuals who have belonged to a registered South African medical scheme for two years or more and have applied to join another scheme within three months of ending their previous membership.

Medical aid members have flexibility throughout the year to downgrade their plans. However, there is a period in the year, from October to December, when members can upgrade their plans.

If your medical aid needs an upgrade or a downgrade, here are some key questions that Phillips recommends to help guide your decision.

Health

• What is your personal health history?
• Do you have any existing chronic conditions or upcoming medical procedures?
• Do you have any benefit limits (doctor or hospital networks) or exclusions?
• Did you look into the benefit changes effective in 2026 and how this will affect your cover?

Finances

• What is your comfortable budget for monthly contributions?
• Did you take into account premium increases effective in 2026?
• Do you have an emergency fund (or gap cover) for any uncovered medical costs?
• Based on past claims, is your current plan (including your Medical Savings Account) sufficient?

Timing

• When is your scheme’s “open season” where you can change plans penalty-free?
• Have you factored in a one-month notice to ensure there is no break in your coverage?
• Have you taken into account any waiting periods that may apply?

The power of professional advice

You should consult with a financial adviser to ensure that you are on a benefit option appropriate to your needs – and to make sure that you have allocated enough available savings to last the full year. An independent adviser can provide personalised guidance, compare different options from various medical aid schemes, and make sure the decisions you make align with your long-term financial goals.

Knowing that you and your family have a reliable safety net in the event of illness or injury provides immense peace of mind, so add a medical aid review to your to-do list each year to stay protected.

* Phillips is the head of business development at GrowthHouse.

PERSONAL FINANCE