Calculators & guides
How to read a medical aid plan and benefit schedule
By Naledi Mokoena · 7 min read · Updated 24 June 2026
A medical aid benefit schedule lists what the plan pays, at what rate, and where the limits sit. To read it, start with the hospital rate, then the day-to-day or savings structure, then the sub-limits and co-payments that quietly cap each benefit. The jargon is the same across most schemes once you know the terms.
This guide explains the key terms and shows you where the catches usually hide.
If you can read one benefit schedule properly, you can compare any two plans with confidence.
Start with the scheme rate
Almost everything is paid as a percentage of the scheme rate (sometimes called the scheme tariff). A plan that pays hospital costs at 100% of scheme rate covers the scheme's benchmark price. But specialists often charge 200% or 300% of that rate, so even on a good plan you can be left with a shortfall. The cover rate is the single most important number on the schedule.
Day-to-day: savings vs threshold
Day-to-day claims (GP visits, dentistry, optometry, medicine) are funded in one of three ways:
- Medical savings account (MSA): your own ring-fenced money for the year.
- Above-threshold benefit: once you spend a set amount, the scheme starts paying again.
- None: a pure hospital plan covers nothing day to day.
Know which one your plan uses, and what happens when it runs out.
Sub-limits and the small print
Even inside a benefit, a sub-limit can cap a category. A plan might cover dentistry but limit specialised dentistry to a fixed Rand amount, or cap optical at one frame every two years. Read the per-category limits, not just the headline annual limit. Sub-limits are where members get caught out mid-year.
Co-payments, deductibles and networks
- A co-payment is a fixed amount you pay on a procedure, such as a scope or an MRI.
- A deductible is an upfront amount before the scheme pays at all.
- A network plan only pays in full if you use the scheme's chosen hospitals, doctors or pharmacies.
Use a non-network provider or skip pre-authorisation and you may face a penalty even on a fully covered procedure.
Find the PMB and chronic section
Every schedule has a prescribed minimum benefit and chronic section. This tells you which chronic conditions are covered, the formulary medicine, and the designated service providers. Because PMBs must be paid in full by law, this section is where you confirm your condition is protected regardless of how basic the plan looks elsewhere.
Frequently asked questions
What is the scheme rate on a medical aid plan?
The scheme rate is the benchmark price the scheme uses to pay claims. Benefits are paid as a percentage of it. A plan paying 100% of scheme rate can still leave a shortfall when a specialist charges 200% or 300% of that rate.
What is a medical savings account?
It is a portion of your contribution ring-fenced for day-to-day claims like GP visits and medicine. It is your money for the year. Once it runs out, you pay cash unless the plan has an above-threshold benefit that kicks back in.
What is a sub-limit?
A sub-limit caps a specific benefit category, such as a Rand limit on specialised dentistry or one optical frame every two years, even if the overall annual limit is much higher. Sub-limits are a common reason a claim is only partly paid.
What is the difference between a co-payment and a deductible?
A co-payment is a fixed amount you pay on a specific procedure, like a scope. A deductible is an upfront amount you pay before the scheme starts paying at all. Both are ways the plan shares cost with you.
Why does my plan only pay if I use certain hospitals?
That is a network plan. It keeps contributions lower by paying in full only at chosen hospitals, doctors or pharmacies. Use a non-network provider and you may face a penalty or co-payment, except in a genuine emergency.
Where do I find chronic and PMB cover on the schedule?
Look for the prescribed minimum benefit and chronic section. It lists covered chronic conditions, the formulary medicine and the designated providers. Because PMBs must be paid in full, this confirms your condition is protected even on a basic plan.
