SA actuaries warned that Gap Cover, medical schemes and primary healthcare plans are shifting costs between products, undermining efforts to control healthcare spending.
Presenting at the Actuarial Society of SA convention, Medscheme actuaries highlighted delayed prescribed minimum benefit (PMB) reform as a key concern. PMBs accounted for 70% of scheme healthcare spending in 2025, while contributions increased by an average 8.1% annually between 2022 and 2026.
Around 75% of hospital admissions resulted in out-of-pocket payments. Gap Cover claims exceeding R50,000 increased by 13% annually between 2021 and 2026. Actuaries warned that Gap Cover weakens incentives to use scheme networks, reducing schemes’ negotiating power and contributing to rising provider tariffs. Meanwhile, primary healthcare plans and cheaper hospital options risk fragmenting benefits and weakening cross-subsidies.
They recommend greater co-ordination between schemes and insurers, clearer payment rules and better alignment of provider networks to contain costs without waiting for legislative reform. – Smart about Money (17 October 2026)