South Africans face another tough year of increasing medical aid scheme costs in 2026.
Weighted average premium increases range between 6% and 9%, depending on the benefit option, despite the Council for Medical Schemes (CMS) recommending that increases be limited to inflation (3.3%) plus reasonable use.
Across the country’s leading open medical schemes, the announced increases are 7.2% for Discovery, 8.8% for Bonitas, 8.46% for Medihelp and 6.8% for Bestmed (6.8%). While these increases are marginally lower than those for 2025, the combined effect of electricity hikes, fuel inflation and rising food costs means household budgets are stretched to breaking point.
Martin Rimmer, CEO of Sirago Underwriting Managers, says for many households the cost of medical scheme membership consumes a significant portion of monthly disposable income, yet it remains a non-negotiable given the state of the public healthcare system.
“Even for those with employer subsidies, affordability has become a growing challenge as both employees and employers face tightening economic conditions.”
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Paying more for less: the reality of medical inflation
Medical scheme contributions increase each year, driven by higher claims costs, increased utilisation and an ageing membership base. As a result, members are paying more but receiving less cover, facing escalating co-payments, penalties, sub-limits and out-of-pocket expenses.
“Medical schemes simply cannot keep up with the rate of medical inflation while keeping premiums affordable. The result is continual benefit erosion and an increase in member exposure to self-funding.”
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Gap cover claims reveal the true cost pressure
Sirago’s five-year analysis of gap insurance claims (2021–2025) reveals a sharp increase in claim values, a clear indicator of benefit erosion as well as the buy-down trend toward more affordable “core” hospital plans.
Rimmer explains that gap cover protects members from the shortfall between what specialists charge and what medical schemes pay for in-hospital procedures. Specialists often bill 300% to 500% above the agreed medical scheme tariffs, leaving members liable for the difference, often tens of thousands of rands.
“A few years ago, the average mega gap claim was between R6 000 and R12 000. Today, we see daily mega claims exceeding R50 000, a symptom of affordability pressures and widening gaps between medical scheme tariffs and provider fees.”
The increase in high-value claims underscores the need for members to review their cover carefully and understand the implications of buying down to lower cost options. While these options reduce monthly premiums, they also come with limited benefits, stricter rules and more penalties for non-compliance, significantly increasing the risk of out-of-pocket costs if no gap cover policy is in place.
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Planning your healthcare funding strategy for 2026
Medical aid scheme members have until the end of November 2025 to make benefit option changes to be effective from 1 January 2026. Sirago advises members to work closely with their financial advisors to assess their personal needs, compare relevant options and craft a sustainable healthcare funding solution.
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Rimmer has these tips for consumers to keep in mind when deciding on their medical aid scheme cover for 2026:
- Maintain your medical scheme membership: Do not delay joining a medical scheme or rely on enrolling later in life. Late joiner penalties and waiting periods apply, including a three-month general and 12-month condition-specific waiting period if you had a break in cover.
- Analyse your day-to-day spending: Review how much you spent out-of-pocket versus what your medical aid scheme covered. Overspending or underutilising benefits may mean you are on the wrong option.
- Consider chronic conditions: If you or a dependant have a chronic illness, ensure that it is registered with the medical aid scheme and covered under the Prescribed Minimum Benefits (PMBs) list and that the prescribed medication is part of the scheme’s medicine formulary. Evaluate whether savings from a cheaper option justify the potential loss of chronic benefit access.
- Know how much you can self-fund: Lower premiums mean fewer benefits. Be realistic about what you can afford to self-fund and consider setting up a dedicated medical savings card/account for routine care and medication.
- Get gap cover: Gap cover bridges shortfalls for in-hospital procedures.
- Understand core plans: Hospital or “core” plans only cover in-hospital events. Members must self-fund all GP visits, medication, dentistry and optometry. Consider pairing such a plan with a complementary health insurance product that provides primary care benefits.
- Stay in the same scheme if possible: If you’re changing options, try stay within your current scheme to avoid waiting periods. Most allow a “buy-down” any time during the year, but “buy-ups” are generally only permitted at the start of a benefit year.
- Beware of waiting periods: Waiting periods and late-joiner penalties can apply even when switching between schemes.
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