Many South African medical aids limit or exclude dentistry expenses to keep premiums affordable, leaving families to plan for costs like braces. Financial experts recommend auditing benefits and setting up dedicated savings. Supplementary options like dental gap cover can bridge shortfalls.
South African medical schemes are structured to pool risks for major, unpredictable events such as heart attacks, accidents, and cancer, according to independent financial adviser Kenny Meiring. However, dentistry often falls outside this model because much of it involves predictable maintenance—like check-ups and fillings—or elective procedures such as orthodontics and implants.
To maintain affordability for the wider membership pool, most schemes cap or exclude significant dental benefits. The Medical Schemes Act mandates full funding for prescribed minimum benefits (PMBs), which cover life-threatening or chronic conditions. Ordinary dental issues, including braces and implants, do not qualify as PMBs unless linked to a qualifying diagnosis, like oral cancer or severe systemic infection.
Routine dentistry, such as check-ups, basic fillings, and simple extractions, is typically paid from a member's medical savings account. Hospital-based oral surgery for trauma or impacted teeth may be covered, subject to authorisation and restrictions. Once savings are depleted, orthodontics, implants, and dentures are usually not reimbursed.
Meiring advises auditing current benefits by checking the annual dental sub-limit, orthodontics coverage percentage and maximum, network restrictions, and required authorisations. With schemes now publishing 2026 options and premiums, families should compare if extra premiums justify enhanced dental benefits.
If coverage remains limited, opening a separate investment account funded by monthly debit orders provides a financial cushion for inevitable expenses. Additionally, dental gap cover—a supplementary insurance—can help with shortfalls on certain procedures, though it includes waiting periods and exclusions and does not replace medical aid.
Dental care requires proactive planning beyond relying on medical schemes alone, Meiring notes.