Bianca Visagie - Healthcare Specialist

17/06/2026

Fedhealth - FlexiFED Savvy

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16/06/2026

FaNews

Affordability pressures reshape South Africa’s medical schemes industry

June 2026 | Healthcare | General | Paresh Prema, Branch Head:

Technical and Actuarial Consulting Solutions at Alexforbes Health
South Africa’s medical schemes industry remains under pressure from rising healthcare costs and declining participation among younger members, while employment conditions ensuring a greater proportion of beneficiaries being members of restricted schemes, according to the latest Medical Aid Insights report from Alexforbes.

The report analyses data from 2000 to 2024, drawn from annual Council for Medical Schemes disclosures and focuses on the 10 largest open and 10 largest restricted medical schemes by principal membership. It highlights changing membership patterns, growing affordability pressure, financial strain and the uncertainty created by regulatory reform.

The findings point to a sector that remains stable in overall size, but is under mounting pressure from higher healthcare utilisation, rising provider costs and an ageing beneficiary base.

These trends suggest that while the sectors remained broadly resilient, it is entering a more complex period in which affordability, membership composition and regulatory uncertainty will all shape future sustainability.

Affordability pressures shift membership patterns

South Africa’s medical schemes industry has remained relatively resilient, but financial pressure and affordability challenges are reshaping the sector. While overall membership has held up, the beneficiary mix is shifting and this is changing the long-term outlook for schemes.

Medical schemes still cover more than 9 million beneficiaries, but growth is increasingly concentrated in restricted schemes while open schemes continue to lose ground. This points to the growing impact of affordability pressures in the industry and the appeal of employer-supported cover in restricted schemes. At the same time, fewer younger beneficiaries are joining schemes, while the pensioner ratio continues to rise.

Healthcare costs remain a major challenge, driven by higher utilisation, rising provider fees and continued advances in medical technology. An ageing medical scheme population and a growing burden of chronic disease are also pushing up claims, with contribution increases continuing to outpace inflation.

The introduction of the National Health Insurance Act and broader regulatory reforms are reshaping the landscape. Ongoing legal challenges, along with significant concerns about the Act’s constitutionality and feasibility, are creating uncertainty, while also underscoring the importance of clarifying the future role of medical schemes.

Membership Trends

Despite reductions in the number of medical schemes, the industry has grown by 1.3 million principal members (46%) and 2.2 million beneficiaries (32%) since 2005. Excluding Sizwe Hosmed, the remaining 70 medical schemes operating in South Africa at the end of 2024 had a total of 4.11 million principal members and 9.04 million beneficiaries. Between 2023 and 2024, open schemes experienced a 1.2% decline in membership, while restricted schemes saw a 2.4% increase, resulting in a net growth of 0.6% in total scheme beneficiaries.

Between December 2023 and December 2024, no open medical schemes recorded a year-on-year increase in beneficiaries exceeding 5%. In contrast, six restricted schemes experienced beneficiary growth above 5% during the same period. These included Alliance-Midmed (5.8%), Foodmed (5.1%), GEMS (5.2%), LA Health (6.7%), Retail Medical Scheme (5.3%) and Umvuzo (5.3%).

Financial strain intensifies across the sector

The overall risk claims ratio rose from 95.8% in 2023 to 96.2% in 2024. Open schemes recorded a ratio of 91.9%, while the ratio of restricted schemes reached a significant 101.3%.

Non-healthcare expenditure (NHE) as a percentage of gross contribution income (GCI) declined slightly across the industry, from 7.92% in 2023 to 7.85% in 2024. Open schemes improved cost efficiency with a decrease from 9.64% to 9.51%, while restricted schemes saw a marginal increase from 5.65% to 5.71%.

Solvency levels remained a key focus, with 8 of the top 10 open schemes and all top 10 restricted schemes meeting the statutory minimum of 25% at the end of 2024. The open schemes that failed to meet the 25% statutory minimum solvency were Medihelp and CompCare. Their solvency levels were 21.0% and 21.8%, respectively. The last known solvency level for Sizwe Hosmed was 6.62% in July 2025, according to a CMS media report published on 3 September 2025, down from 15.7% in 2023.

The industry recorded an operating deficit of R11.64 billion in 2024, up from R10.20 billion in 2023. The weaker performance was largely driven by restricted schemes, where claims ratios increased between 2023 and 2024. Thebemed was the only open scheme to record an operating surplus in 2024, while five of the 10 restricted schemes recorded operating surpluses. Many schemes that recorded operating deficits had to rely on investment income to help absorb claims and administration costs. After investment income, seven out of 10 open schemes and seven out of 10 restricted schemes achieved a net surplus.

Sustainability remains a key watchpoint

Significant improvements were observed in the sustainability index for 2024. Thebemed led with a 15.2% increase, followed by Polmed at 14.1%. Both schemes reported operational and net surpluses in 2023 and 2024. Improved solvency levels were a key driver of these stronger results; however, Polmed experienced a 0.4% decline in beneficiaries. Among open schemes, Discovery and Momentum showed the most notable gains, improving by 11.9% and 9.5% respectively.

The findings highlight growing pressure on affordability, sustainability and access to private healthcare cover in South Africa.

You can view the full report here.

Healthcare Adviser

15/06/2026

Bestmed

14/06/2026

11/06/2026

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11/06/2026

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11/06/2026

SPONSORED |The future of healthcare is not private or state, but hybrid. Corporates must plan to adapt their benefit structures accordingly or risk coverage gaps and duplicate costs

10/06/2026

Dear Bonitas Member,

During the current transition of administrators, I want to assure you that I am doing everything possible to assist each and every client experiencing challenges.

I am dedicating several hours daily to calls and follow-ups regarding authorisations, medication queries, membership concerns, and other urgent matters. Due to the exceptionally high volume of queries and extended waiting times, I may not be able to respond as quickly.

I understand how stressful and frustrating this situation can be, especially when it impacts your healthcare and access to benefits. Please know that your concerns are important to me.
I remain committed to supporting you and advocating on your behalf.
Bonitas and their teams are working around the clock to clear the backlog and restore normal service levels as quickly as possible.

Thank you for your patience & understanding, and continued support during this time..

10/06/2026

I’m on a top medical aid plan – I don’t need gap cover… or do I?
May 2026 | Healthcare | General | Tony Singleton, CEO at Turnberry Management Risk Solutions

▶️ Many South Africans on top-tier medical aid plans believe they are fully covered for any medical event.

However, while these plans offer broad benefits, access to private healthcare and higher reimbursement levels, this perception does not always reflect how medical aid cover works. Specialists frequently charge well above scheme rates, co-payments and sub-limits are increasingly common, and even comprehensive plans apply limits to what they will pay. The result is that you can still face significant out-of-pocket expenses, despite paying high monthly contributions. Gap cover plays a critical role in addressing these shortfalls by covering the difference between what medical schemes pay and what providers charge.

▶️ A false sense of security

Premium medical aid options are designed to provide extensive cover, and this often leads to the assumption that your plan will pay the full cost of treatment. This belief is reinforced by terms such as “100%” or “300% of scheme rate”, which can easily be misunderstood as synonymous with “full cover”.

In reality, these percentages refer to the medical scheme’s tariff, not the provider’s invoice. Specialists in fields such as oncology, orthopaedics and neurosurgery frequently charge up to five times the scheme rate, and sometimes more. Even on comprehensive plans, this creates a gap between what is charged and what your medical aid will pay. Having comprehensive medical aid does not remove your risk of shortfalls, it simply reduces it.

▶️ Where costs exceed cover

The most common out-of-pocket expenses on top medical aid plans arise from specialist shortfalls, co-payments and benefit limits. These are not limited to major procedures or even serious and complex cases. They can and do occur across a wide range of medical scenarios.

Procedures involving multiple specialists, such as surgery, can result in several separate shortfalls across surgeons, anaesthetists and assisting doctors. Oncology treatment is another area where costs can escalate quickly, particularly where schemes impose sub-limits on treatment protocols.

Co-payments have also become more prevalent as schemes manage rising healthcare costs. These can be required upfront before treatment proceeds and may amount to tens of thousands of Rands.

Understanding how medical aid pays for treatment and where shortfalls can arise helps to put these gaps into context. This makes it easier to see why additional cover may be necessary.

▶️ Making medical aid work harder for you

Gap cover is designed to work alongside medical aid, not replace it. While medical aid provides access to private healthcare, gap cover addresses the medical expense shortfalls that arise when scheme benefits do not fully match provider charges.

By addressing these shortfalls, gap cover helps to prevent you from having to use savings, take on debt or compromise long-term financial plans to cover for medical expenses. It also means that treatment decisions do not need to be dictated by what you can afford to pay out of pocket.

It is important to remember, however, that gap cover must be aligned with your specific medical aid option to ensure that it addresses the actual areas of exposure. Even on top-tier plans, this additional layer of protection has become an essential part of managing healthcare costs effectively.

▶️ Ensuring your cover works when it matters

Medical aid remains a critical part of accessing quality healthcare, but it does not eliminate financial risk, even at the highest levels of cover. Rising costs, higher specialist fees and evolving benefit structures mean that shortfalls are an ongoing reality.

Gap cover is a practical way to manage this risk by covering the difference between what medical schemes pay and what treatment actually costs. When structured correctly, it helps to ensure that a medical event does not become a financial setback.

Speaking to a broker or financial advisor can help you understand where your medical aid may fall short and how gap cover can be structured to provide the right level of protection for your needs.

📞 082 309 7012
Bianca Visagie Healthcare Adviser
Nexus IFP