Here's what you need to consider before making medical plan choices for 2025

Medical plan participants are currently required to choose their 2025 health plans.

There are important factors to consider as you make your health insurance choices for next year, although it’s difficult to keep up with ever-increasing premiums that appear to be very high for 2025.

With the cost of living rising, healthcare coverage can feel like a luxury, especially for young, healthy South Africans. However, with policy debates over National Health Insurance (NHI) and private healthcare, membership of medical schemes remains essential and provides crucial protection against unpredictable medical costs, says Dr Rajesh Patel, head of healthcare system strengthening at the Board of Healthcare Funders (BHF), says .

Members of the medical scheme feel the pressure from the recent premium increases and many of them may consider reducing their options or even opting out altogether. However, Patel warns that continued medical scheme cover is crucial for maintaining financial security and supporting your long-term health.

Reports from the Council for Medical Schemes (CMS) show that South African medical schemes collected R232 billion in premiums and paid more than R218 billion in claims for approximately 9 million beneficiaries during 2023/2024.

These funds covered a wide range of health care needs, from hospital stays and advanced procedures to life-saving medications.

That is why your premiums increase

Patel identifies these key drivers behind increasing premiums for medical plans:

Medical inflation and rising healthcare costs: Healthcare costs have consistently risen faster than overall inflation, thanks to advances in medical technology, new treatments and more expensive medications. Medical systems must adjust premiums to keep pace with these rising costs to ensure adequate coverage for members.
Increasing prevalence of chronic diseases: Chronic diseases, such as diabetes, high blood pressure and heart disease, are on the rise. These conditions require ongoing and often costly management, contributing to higher value claims and higher premiums.
Deferred costs due to the Covid-19 relief measures: During the pandemic, many medical plans did not increase premiums to ease members’ financial pressure, leaving a funding gap. Now, medical programs must fill this gap to maintain financial sustainability and continued access to quality health care.

Patel says it’s still important to remain a member of a medical program. “Reducing or opting out of medical plan coverage may seem like a quick way to save money, but it can lead to long-term financial risks and higher costs.”

READ ALSO: Rising costs of medical care require urgent attention

Why it is important to stay connected to a medical program

It is important to stay covered because:

You are protected against high medical costs: Medical costs can be unpredictable. Emergency care, operations and specialist treatments can cost hundreds of thousands of rands. Medical plans protect members against these high costs and guarantee access to care when you need it most.
You avoid fines for late entry and waiting times: Members who terminate their membership and attempt to rejoin later may face high late-joining penalties, increasing your premiums by up to 75%. The Medical Schemes Act 1998 imposes these penalties to ensure fairness between long-term contributors and those who only seek cover later when health problems arise. By staying covered, these penalties are avoided and premiums remain affordable.
Access to preventive and welfare care: Many schemes offer preventive care, including wellbeing checks, screenings and mental health support. Preventive care detects health problems early and reduces the risk of serious complications that are more expensive to treat, making it invaluable for proactive health management and long-term savings.
Coverage for chronic and unexpected conditions: Medical conditions can develop unexpectedly and at any age. Continuous coverage guarantees access to necessary care for both chronic and acute conditions, including lifestyle-related diseases such as hypertension and diabetes. Residency in a medical program provides consistent access to the treatment and management of these conditions.

READ ALSO: Coverage ratio analysis shows massive erosion in benefits of medical schemes

How to Choose the Best Medical Plan

Patel says you should consider these steps if you’re considering adjustments to your coverage to ensure you select a plan that balances affordability with essential benefits:

Evaluate your health profile: Assess your current health, family medical history and lifestyle. Healthy individuals can consider plans that prioritize preventive care, while those with chronic conditions should choose options that include specialist visits, medications, and ongoing treatment.
Focus on essential coverage: If you’re concerned about premiums, consider plans that cover essential hospital and emergency needs. These options offer high-cost protection without extensive extras, keeping premiums manageable while ensuring important coverage. A consultation with your scheme or broker can help you identify the best options for your budget and health needs.
Participate in wellness programs: Many programs reward healthy lifestyle choices through wellness programs and offer incentives such as discounts. Participating in these programs reduces costs and promotes healthier living, providing financial and personal health benefits.

Always remember the long-term value

You should always keep the long-term value of staying covered in mind, Patel says. “Remaining in a medical program is about more than immediate health care needs. It’s about long-term security, both for your health and your finances. Medical plans provide the peace of mind that, should an emergency arise, you are protected from the high costs of private healthcare.”

He points out that there is a push for affordable, accessible healthcare for all. “With healthcare costs rising, the BHF is calling for better affordability and accessibility. It has that purpose called in the Competition Commission to make collective bargaining possible between plans and providers, while CMS is urged to revise the costly Prescribed Minimum Benefits (PMBs) to emphasize preventative and primary care.

In addition, Patel says the BHF is also calling on the Health Secretary to implement regulations under the Medical Schemes Act for a more affordable PMB package that enables low-cost basic benefit options that would increase access to medical schemes and improve healthcare and financial security promote. throughout the country.