Karin Mitchelmore, Executive Head of Healthcare Consulting at advisory firm, NMG Benefits

For many South Africans, a large part of ‘Janu-worry’ lies in how they will fit the annual medical scheme increase into their monthly budgets. For 2026, members can expect an average increase from anything between 7.2% and 9.9% which is still higher than both the current inflation rate and a typical annual salary increase. However, understanding why these increases happen and how to make informed choices about medical cover can make a real difference.

Medical scheme contributions rise each year largely because of the cost of private healthcare. “There is a huge amount of pressure on the system,” explains Karin Mitchelmore, Executive Head of Healthcare Consulting at advisory firm, NMG Benefits. “Costs are soaring, and schemes have a responsibility to their members to remain sustainable. In some cases, this means adjusting the cost of comprehensive plans in line with the usage patterns of their members, who often choose these plans because their healthcare needs are higher. Members with fewer needs often choose plans with limited benefits and, while annual increases on these plans may be lower, careful budgeting is still key.”

Deciding whether to up- or down-grade your plan, or switch your scheme entirely, cannot be informed solely by cost. Mitchelmore points out that this decision requires a careful look at your personal circumstances: “It is vital to consider your family makeup and medical requirements, as well as your budget, before making any changes. For those with young families or chronic conditions, a comprehensive plan may remain essential. Others might find a lower-tier plan adequate for their everyday needs and emergency care.”

Time is also critical. Most schemes only allow plan upgrades once a year, effective 1 January. After that, you may have to wait until the following year unless you experience a qualifying life event. Downgrades are usually allowed at any time, but medical savings account usage and benefit allocations may affect how much is carried over and members may end up having to pay in a lump sum to compensate for limits that they reached before making the switch.

Gap cover is another piece of the puzzle. This is a separate insurance policy that covers the difference between what a medical scheme will pay for hospitalisation, certain procedures and what these services actually cost. While cover at 100% or 200% of the medical scheme rate may seem sufficient, the reality is that costs can far exceed this and it is the member’s responsibility to ensure that all these bills are paid in full. The good news is that gap cover is relatively inexpensive, and many providers are offering new options aimed at making the monthly premium even more affordable.

Medical schemes are also constantly innovating to help manage costs and provide more value for their members. Health-tracking programmes encourage members to monitor lifestyle factors like activity, nutrition, and sleep. Preventative care and screening benefits are growing in importance, encouraging members to get tested to help detect diseases before symptoms appear. Early detection could save your life and avoid you having to pay enormous bills for advanced disease treatment or hospitalisation later. Networks for virtual consultations with GPs and some specialists are expanding to increase access for members in remote areas, while provisions for mental health conditions are being widened. Some schemes are also acting on studies which show that certain patients recover better at home than in hospital and are ramping up benefits for at-home checkups and care accordingly.

The upshot of all these changes, says Mitchelmore, is that medical scheme benefits are getting increasingly complex to understand. “Consulting with a medical scheme advisory expert can help ensure that you have cover for your needs without paying for benefits that you are unlikely to use. NMG Benefits’ team of independent advisors guides members to analyse their needs and identify the most suitable plans and, because of the preferred provider pricing arrangements can secure prepared pricing for Gap Cover as well as Primary Care Insurance solutions. Act now and don’t leave these important decisions to the end of December which may be too late.”