Medical scheme increases in the spotlight
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these reserves by announcing unusually lower contribution increases in 2021 and 2022. These low increases put those schemes in deliberate loss-making positions so that claims being paid to members were higher than contributions collected from members thus allowing members to temporarily benefit from the higher levels of reserves. However, a loss-making position can t be sustained indefinitely and reserve levels are now slowly reducing minimum required levels with schemes now returning pricing to sustainable levels by increasing contributions. She explains that for open medical schemes, utilisation can
account for as much as 6%.
“Bearing in mind that conceptually the CMS indicated increases should be limited to tariff plus reasonable utilisation estimates, their guidance is reasonable. The result of these higherthan-CPI increases particularly given that the average salary increases are only expected to be about 6% this year means that medical aids are becoming unaffordable for many people.
Towert says this is an unfortunate consequence of a stagnant and fragmented regulatory environment. Medical schemes are subject to unreasonable and extremely expensive prescribed minimum benefit (PMB) requirements which have not been substantially revised for more than 20 years (even though the act requires regular revisions). The world has changed, but PMBs have not. The act requires that medical schemes must pay health care providers in full, at whichever cost they choose to charge for these PMBs, unless the scheme can negotiate a contract with those providers. Other issues include the imposition of open enrolment,
which means that schemes cannot refuse an applicant cover, and community rating, which means everyone in a benefit option must pay the same premium. Over the past two decades, these rules have resulted in an ongoing deterioration of the lives covered by medical schemes. Younger, healthier lives are allowed to choose not to belong to medical schemes until healthcare is needed and voluntarily opt out of the system. As such, the remaining lives being covered by schemes are progressively becoming
Mental health focus among new benefits
Although it kept its contribution increases well below the industry average for the past few years, Bonitas Medical Fund has announced a weighted increase of 10.2% for 2025. Principal officer Lee Callakoppen says the scheme has had to take measures to prevent instability in its environment.
“The increases are meticulously calculated by our actuaries, balancing the financial sustainability of the scheme, while adhering to regulatory guidelines and requirements outlined by the Council for Medical Schemes (CMS). Over the past few years, we managed to keep our contribution increases well below the industry average, while maintaining a healthy financial position and ensuring benefits are not eroded. However, the medical scheme industry has faced turbulent conditions over the past 12 months with the debate over NHI, economic pressures and reserves coming under pressure he says. Bonitas contribution increases, which have been submitted to the CMS and are subject to approval, range from 8.7% to 14.9% per plan, with the latter impacting only 1% of members.
In calculating the changes, the scheme considered market trends, including international health care protocols, industry analysis, benchmarking reports and benefit utilisation patterns. Integral to this process was independently commissioned research across core stakeholder groups including brokers, HR representatives, corporates and local government, says Callakoppen.
Recognising the direct correlation between chronic diseases and mental health, for 2025 the scheme has added a mental health component to its GP network, to facilitate early disease detection, diagnosis and multidisciplinary care coordination, through a highquality network of doctors. In addition, it will be providing more personalised engagement and support, through an enhanced maternity programme, to treat antenatal and postnatal depression. Other new benefits include hearing loss management which includes free online hearing screening for all South Africans, not only scheme
members. Bonitas members on selected plans will receive hearing aids, audiology services and hearing aid acoustic services, if they use a network provider
A weight management programme, led by a biokineticist registered with Biokinetic Association of SA, provides a holistic approach to weight loss that includes access to a dietician and psychologist for support on exercise, nutrition and mental health. Obesity or being overweight substantially increases the risk of morbidity from at least 15 conditions, including hypertension, coronary artery disease, diabetes, strokes, sleep apnoea, respiratory problems and cancer ” says Callakoppen. The scheme is making a renewed commitment to the health and wellbeing of women and toddlers through the Mother and Child Care Benefit, including the Maternity Programme. Launched earlier this year in collaboration with CareWorks, the programme emphasises preventative care and early detection of femalespecific health issues Our enhanced Maternity Programme includes support for expecting mothers, including early identification and weekly engagement for high-risk pregnancies, post-childbirth care and associated mother mental health follow-up calls, given the prevalence of pre and postnatal depression. It includes milestone reminders for children under three, immunisation reminders and online screenings for infant and toddler health and screening by an ophthalmologist for premature neonates, on all options except BonCap. This allows for early intervention and, where
possible, prevents blindness. We ve opted to cover antenatal vitamins on all plans through savings or the Benefit Booster. Bonitas Geriatric Care is a personalised range of screening, prevention and wellness benefits for older members which can be performed in the comfort of their own homes. It includes wellness screenings, vaccines for flu and pneumonia, age-appropriate screening
Anthea Towert.
Lee Callakoppen.
and value without having to buy down to save money, as well as preventive care, mental wellness support and chronic disease management, we aim to provide a holistic approach to health and wellness, he says.
Benefit enhancements include an updated low-income option, easier and more accessible rewards from Momentum, the ability to use these rewards to pay medical scheme contributions and an easy digital process that demonstrates how much consumers can save monthly without having to buy down.
growing and the profile of the market is ageing. Despite all these challenges, McHugh says the sector has shown remarkable resilience and adaptability. The scheme will be introducing benefit enhancements aimed at improving the overall health care experience for its members in 2025. These enhancements reflect our dedication to offering innovative and sustainable health care solutions that cater to the diverse needs of the local market. By focusing on choice
Momentum Health4Me, Momentum Health Solutions health insurance product, has seen significant growth in membership, with an increase of more than 5% over the past six months, reaching a total of more than 220,000 beneficiaries. Designed to provide affordable health care solutions to individuals and families who may not have access to traditional medical aid, Health4Me has expanded its reach and impact to become one of the largest health care insurance providers in the market.
Health4Me has been instrumental in bridging the gap in health care access, offering essential health benefits at an affordable price. The product s growth reflects our commitment to inclusivity and our understanding of the diverse needs of the South African population, says McHugh.
Momentum Multiply, Momentum s loyalty
programme, has provided significant value to its members this year by moving from a traditional loyalty programme to incentivising healthy behaviour. This approach rewards members for knowing and improving their physical and mental health. McHugh says members can begin earning maximum rewards from day one, eliminating the need for points, waiting periods, more policies or income requirements to access full benefits. In 2025, Momentum Multiply will continue to promote healthier lifestyles among members, reinforcing the belief that your health is your wealth. We understand good health is the most important asset one can have. New features and enhancements will be added to the programme to further motivate and support members on their health journeys. These include a digital health and fitness assessment for members, as knowing your health is the first step to improving your health.
Wysa, an emotional intelligent chatbot, has been introduced to support mental
THE BUSINESS ANTICIPATES CONTINUED GROWTH IN THE ADOPTION OF DIGITAL HEALTH TECHNOLOGIES IN 2025
wellness. The AI-powered companion engages members in conversations about their feelings and challenges. Support is provided through evidencebased techniques and strategies and access to a variety of selfhelp resources, including mood trackers, journalling prompts and guided exercises focused on cognitive behaviour therapy, mindfulness and emotional regulation. Private and easy to use, Wysa is available 24/7. By leveraging data and personalised insights, the loyalty programme will continue to offer tailored recommendations and rewards that align with individual health goals, making it easier for members to stay on track and achieve their wellness objectives.
Members will be able to use the rewards they earn to pay their medical scheme contributions, leveraging their health to maintain the cover they need, says McHugh. The business anticipates continued growth in the adoption of digital health technologies and a greater emphasis on personalised care in 2025. By focusing on preventive care, leveraging advanced technologies and providing comprehensive support, a more sustainable health care ecosystem can be established that supports the wellbeing of all South Africans, he says, adding that the scheme remains committed to leading the way in providing innovative, affordable health care solutions that meet the needs of all South Africans.
Customisation offers further flexibility
There s an assumption that when it comes medical aid options in SA, there s a great deal of choice in terms of type of cover and plan whether it’s a basic hospital plan or a comprehensive family option. However, the truth is when it comes to the actual structure of a medical aid plan, there s not as much choice as we assume, says Jeremy Yatt,
Jeremy Yatt.
Damian McHugh.
Members’ interests ‘always our priority’
Get more bang for your buck
The growing cost of medical scheme membership is putting strain on household budgets, particularly for pensioners on a fixed income and those whose incomes are not growing faster than inflation. Encouragingly, there are ways to reduce your medical aid costs. The foundation of
To cover the major gaps left
member interaction. The members best interests and being genuine partners for life will always be our priority, he says. Claims patterns have been reviewed and benefit limits on oncology, external prosthesis and pregnancy scans have been increased. Basic and specialised dentistry, optical and day-to-day benefit limit increases alone are more substantial when compared to our average benefit increase for 2025, says Aron. The scheme recently announced the addition of a WhatsApp service line and a revamped Medshield App. Members are also able to unlock value through Medshield Wellness, MedshieldMOM, Medshield Kids and Medshield Mind, the scheme’s new mental health support programme A mental health medicine benefit has also been included for 2025, as well as the new Medshield Mind support portal, a comprehensive and free web platform designed to provide Medshield members with valuable resources and tools to help them maintain good mental health. Aron says the platform will be user-friendly and easy to navigate, making it accessible to everyone who wants to care for their mental wellbeing.
from lower-than-retail prices. As medical schemes, we offer a safety net for many health care costs, but gaps can occur, especially when the costs of specialists or certain treatments exceed the rates covered by your chosen benefit plan,” says Aron.
Medshield s 2025 product offering features a streamlined suite of benefit options to cater for different health care needs from birth right through to maturity. The scheme currently offers eight benefit options and two efficiency discount options specifically developed to cater for various health care needs. Members need to ensure they are on the right option to eliminate any frustrations and so that they receive the best value in return for their contributions he says. To close the gap for medical shortfalls, Medshield has partnered with leading insurance brands to market gap cover so members can benefit
“Our collaboration with an additional gap cover partner, Sanlam, is designed to close the gap between a member s Medshield plan and the actual costs incurred, ensuring that Medshield members can access quality health care without the stress of unexpected medical bills.” The scheme constantly monitors its membership profile and claims experience on each plan to ensure each one remains sustainable. Based on its monitoring and market trends, it has observed growth in the middle-range options, and therefore decided to discontinue its MediSwift benefit option in 2025. Medshield s 2025 benefit offering and contribution adjustments balance affordability, increase members access to quality health care and ensure Medshield remains a viable and sustainable medical scheme, as evidenced by the scheme s latest AA- with a positive outlook GCR rating. We re a stable organisation with every intention of being around in the long term. As such, our benefit plans cover members needs as they navigate through life, says Aron.
Regulatory intervention ‘urgently needed’
Kevin Aron.
Wood sinks poor Palace
• Notts Forest climb to eighth on the table while Palace are yet to win
Nick Said Nottingham Foreststriker Chris Wood profited from an error by CrystalPalace goalkeeperDean Henderson togive hisside a1-0 Premier League winon Monday thatleavesthe visitorsstillwithout a victory this campaign. Forest led20 minutesinto thesecond halfwhenWood s low strikefrom 23mbeat Henderson athis near postafter the goalkeeper onlymanaged toget weakhandto theballasit squirmed past him into the
Woods poised to make TGL debut in January
Questions about off-court coaching nod
Aadi Nair Nashik World No 6 TaylorFritz saysthe International Tennis Federation s (ITF)decision toallowoff-court coaching from 2025 will ruin the game s oneversus onestrategic and mental elements. The ITF announcedon Monday that off-court coaching will be allowed from January 1 after a decision by the governing body s AGM this month. The change would make tennis fairer and potentially more entertaining Off-court coaching was trialled inall fourGrandSlamsand ATP and WTA tours since 2023. US Open finalist Fritz criticised off-courtcoaching and expresseddispleasure withthe rule change in apost on X on Monday, writing: Canwe stop ruining the 1v1 mental/strategic aspect of the sport PLEASE. Former world No10 Denis Shapovalov said allowing offcourtcoaching was sad tosee. Tennisis specialbecauseyou are out there alone. Why are you trying tochange thebeauty of this game. ITF senior executive director Stuart Millersaid thedecision wasmade afterconsultingwith key stakeholders including players, coaches and umpires. Players feltit wasa positive development and makes tournaments moreinteresting for them. Coacheshave saidit helps player development and helps to improve the standing of their profession, Miller said. Chair umpireshave saiditimproves theirability tofocus onmonitoring the game. / Reuters
Ahmed to join England spinners
Aadi Nair Nashik England have included three spinnersin theirteam fortheir third and final Test match against Pakistanin Rawalpindi, with Rehan Ahmed recalled, the England andWales cricket board said on Tuesday. England won the first Test by aninnings and47 runs,before Pakistan levelled the series with a 152-run victory in Multan with spinduo NomanAli andSajid Khan taking all 20 wickets. Ahmed will feature alongside fellowspinners ShoaibBashir and Jack Leach. Fast bowler Gus Atkinson was also brought in. Ahmed, 20, played his first
Testin 2022duringEngland s tourof Pakistan,taking afivewickethaulon hisdebutasthe visitors completeda 3-0sweep of the series. He san outstandingcricketer. It s not just his bowling, but his battingand fielding.He sa young lad so he has a lot of time to come, said Englandbatter Harry Brook. He gotfive-forin the last Testhere, so hopefully he can do that again.
team:
of members who require highquality care but are mindful of cost. Through a coordinated care model, EVO members use designated health care providers and can only access specialists through GP referrals.
This simple yet effective system, says Moloabi, has reduced unnecessary health care expenditures while maintaining a high standard of care.
However, as we move forward, we need to preserve these reserves for future contingencies and uncertainties and to sustain the quality of services our members have come to expect. Ultimately, it s about managing our financial position responsibly to remain resilient in a volatile health care environment.
Moloabi says affordability has always been central to GEMS’ strategy.
We recognise that many of our members face difficult economic circumstances, which is why we ve been at the forefront of designing innovative solutions that offer the same comprehensive coverage at a reduced cost, he says.
An example of this, he says, is the Emerald Value (EVO) option. Introduced in 2017, EVO was designed to meet the needs
“In 2023, EVO’s contribution rates were nearly 20% lower than those of our standard Emerald option, making it an attractive option for many of our members. What sets EVO apart is not just its affordability, but the strategic care coordination that underpins its success. By ensuring that members work closely with their GPs and specialists, we are streamlining health care delivery, reducing duplication and lowering costs, he says. It s a model which has delivered considerable savings to members while preserving the quality of care, says Moloabi.
EVO is not just a cost-saving measure; it’s a smarter, more sustainable way to manage health care, proving that affordability and excellence can go hand in hand. As members are the scheme s greatest asset, GEMS makes every effort to empower them to make informed decisions about their health care. “We understand that
navigating the complexities of medical schemes can be daunting which is why education is at the core of our member support strategy, says Moloabi. We want members to fully understand the options available to them, from the comprehensive coverage offered by Emerald and Ruby options to the more affordable EVO and Beryl plans. By providing clear, accessible information, we aim to help members make decisions that best align with their health care needs and financial realities. While the upcoming option selection period is an important time for members to reassess their health care needs, he says the scheme s commitment goes beyond this. We continuously educate members on the importance of using their health care benefits wisely, including taking advantage of preventive screenings and understanding how to navigate benefits to minimise out-of-pocket expenses he says.
EMPOWERING MEMBERS
Medical schemes are well aware of the need for health care to be both accessible and sustainable. While the challenges we face, including rising costs, regulatory changes and evolving member needs are not unique to GEMS, our approach to addressing them is. We re not content to simply react to these challenges. Instead, we are being proactive about ensuring the financial sustainability of the scheme, innovating for affordability and empowering members to take control of their health care journeys. Our vision is clear to be a sustainable medical scheme that provides high-quality, accessible health care for all our members says Moloabi. BY PROVIDING CLEAR, ACCESSIBLE INFORMATION, WE AIM TO HELP MEMBERS MAKE DECISIONS THAT BEST ALIGN WITH THEIR HEALTH CARE NEEDS
Dr Stanley Moloabi.
England
Zak Crawley, Ben Duckett, Ollie Pope, Joe Root, Harry Brook, Ben Stokes (capt), Jamie Smith, Gus Atkinson, Rehan Ahmed, Jack Leach, Shoaib Bashir. /Reuters