What it means library
Medical aid and gap cover often come with terms and concepts that can be confusing. Many of these are important for clients to understand before making a decision.
Our What It Means Library is a collection of short explanations of these terms in clear, simple language.
Each guide breaks down a specific concept – from needs analyses and waiting periods to PMBs and medical savings accounts – so you know exactly what it means and how it affects your healthcare cover.
It’s designed to help you understand the details, ask the right questions, and make informed choices about your healthcare.
A Needs Analysis
A needs analysis is the part where we pause, breathe, and ask a very sensible question: what do you actually need from your medical cover? It sounds obvious, but many people choose cover the way they choose snacks when they are hungry — quickly, emotionally, and with a few regrets later.
Medical Scheme Options
A medical scheme option is simply the benefit package you choose within a medical scheme. That sounds straightforward, but this is where things can get confusing very quickly, because not all options work in the same way.
Monthly Contributions
Your monthly contribution is the amount you pay every month to stay on your medical scheme. It is the regular cost of keeping your cover active. Whether you use your benefits that month or not, the contribution still needs to be paid, because it is what keeps your membership in force and your access to benefits available when you need them.
Annual Contribution Increases
Medical scheme contributions usually increase once a year, often at the start of a new benefit year. This is normal in South Africa and is linked to the fact that healthcare costs, hospital costs, and medicine prices do not stay still.
Waiting Periods/Exclusions
A waiting period means you have joined the scheme and you are paying contributions, but certain benefits are not available immediately. Under South African medical scheme rules, a scheme may apply a general waiting period of up to 3 months and, in certain cases, a condition-specific waiting period of up to 12 months for a pre-existing condition.
Late Joiner Penalties
A late joiner penalty is an extra amount that can be added to your monthly contribution if you join a medical scheme later in life without enough previous medical scheme cover. In South Africa, this generally becomes relevant from age 35, and breaks in cover can matter when the scheme assesses whether the penalty applies.
Prescribed Minimum Benefits (PMBs)
PMBs, or Prescribed Minimum Benefits, are a set of minimum health benefits that all registered medical schemes in South Africa must cover by law. They include emergency medical conditions and cover for a defined list of conditions and chronic illnesses.
Medical Savings Accounts
A medical savings account is a portion of your medical scheme contribution set aside for approved day-to-day healthcare expenses, depending on the option you have chosen. It is commonly used for things like GP visits, medicine, and other everyday medical costs, rather than major hospital events.
Network Providers/DSPs
A network provider is a doctor, specialist, hospital, or pharmacy that has an agreement with the scheme to provide services at agreed rates. A DSP, or Designated Service Provider, is the provider a scheme may require you to use for certain PMB-related treatment if you want full cover under the scheme rules.
Pre-authorisation
Pre-authorisation is when the scheme needs to approve certain treatment, procedures, scans, or hospital admissions before they happen. It is a normal part of medical scheme administration and is especially common for planned hospital care and some specialised services.
Submitting a Claim
Submitting a claim means sending your medical account to the scheme so it can pay the provider directly or reimburse you if you have already paid. Sometimes the doctor or hospital sends the claim for you. Sometimes you need to submit it yourself through an app, website, email, WhatsApp service, or member portal, depending on the scheme.