Makoti Health Plan (Good Hope Medical Aid Society)

R438 to R1 207 for the principal member depending on income. Read the phrase "Services accessed in State Hospitals only" in the guide before anything else, because it governs the whole option.

• Hospital. All in-hospital care is in state facilities. Prescribed Minimum Benefits are covered in full as authorised, including emergency stabilisation, under section 67(1)(g) of the Medical Schemes Act. There is no private hospital benefit apart from maternity.
• Specialists. Prescribed Minimum Benefits only, in state hospitals, on referral from your nominated GP and with pre-authorisation. If you want to see a private specialist for anything, you pay for it yourself.
• GP. Unlimited primary healthcare from the one GP you nominate, paid at the Makoti Scheme tariff.
• Medicine. Acute and chronic medicine as per the scheme formulary. Over-the-counter generic medicine is capped at R475 per family per year, which is roughly one item a month.
• Pathology. Cover is restricted to eleven named tariff codes: liquid based cytology, vaginal or cervical smears, quantitative glucose, glycosylated haemoglobin, haemoglobin estimation, platelet count, HIV Elisa, RPR, ABO grouping, Rh grouping and total white cell count. Anything a doctor orders outside that list is yours to pay.
• Radiology. Chest X-ray, suspected fractures of extremities, and two obstetric sonars per pregnancy. Nothing else is listed.
• Maternity. Confinement in a private hospital to a maximum of R30 870, with pre-authorisation in the second trimester. This is the one benefit that breaks the state-hospital rule.
• Internal prostheses. Limited to R61 728 per family per year. The guide does not explain how a prosthesis limit works alongside a state-hospital-only admission rule. Ask the scheme before you count on it.
• Dentistry. Consultations, fillings, extractions and prevention through an accredited dentist or dental therapist, with pre-authorisation from Dental Information Systems. No specialised dentistry and no dentures at all.
• Optometry. R1 180 per beneficiary every 24 months, covering the eye test, frames and lenses together. Pre-authorisation required, refraction error of 0.5 dioptre or more, no replacement of lost spectacles.
• No published benefit for psychology, physiotherapy, occupational therapy, dietetics, speech therapy, audiology, hearing aids, external appliances, oncology or organ transplants. Where those are Prescribed Minimum Benefits they are covered in a state facility. Where they are not, there is no benefit.

R3 025 to R4 137 for the principal member depending on income. Hospital cover is unlimited in private hospitals and day hospitals, subject to pre-authorisation, clinical protocols and PMBs, with step-down facilities where medically appropriate.

• GP. Unlimited primary healthcare from your nominated GP at the Makoti Scheme rate. The nomination rule is identical to Primary.
• Specialists, radiology and pathology. Covered on referral by your chosen GP, subject to pre-authorisation and managed care protocols. There is no published rand limit and no published percentage of tariff above 100%.
• Medicine. Acute and chronic on the formulary. Over-the-counter generic medicine capped at R505 per family per year.
• Maternity. Confinement at any private hospital, subject to pre-authorisation and scheme protocols. No rand cap is published, unlike Primary.
• Oncology. Chemotherapy, radiotherapy, radiology, related consultations and pathology are limited to PMB level of care as authorised under the ICON treatment plan, with no benefit for biologicals or brachytherapy materials. This is the single biggest gap on the option.
• Mental health. Clinical psychology limited to 8 consultations per family per year, on GP referral and pre-authorisation. The 2026 guide says these are paid "at agreed 2025 rate", which appears to be a drafting error carried over from the previous year. Confirm the rate before booking.
• Allied health. Physiotherapy, occupational therapy, dietitians, podiatry, speech therapy and audiology share a single pool of 20 consultations per family per year.
• Prostheses. Internal to R64 815 per family per year, with cardiac stents limited to three, one per lesion. External orthopaedic prostheses, wheelchairs, walking frames, crutches and home oxygen share R4 245 per family per year. Glucometers R315 per member every 24 months.
• Hearing aids. R4 285 per beneficiary every 4 years.
• Dentistry. Basic dentistry per managed care protocol, plus specialised dentistry to R4 420 per family per year, which has to cover root canal treatment and all periodontal treatment for everyone on the membership.
• Optometry. R3 270 per beneficiary every 24 months, including multifocal and contact lenses.
• Other. DBC back and neck programme, one flu vaccination a beneficiary a year, HPV vaccination for female beneficiaries, one pneumococcal vaccination every 5 years for immune-compromised beneficiaries and those over 65, COVID-19 vaccines and tests on protocol, organ transplants and kidney dialysis subject to PMBs with the donor's costs excluded, and emergency room or casualty for life-threatening emergencies only.

The chronic care benefit covers the 27 conditions on the statutory Chronic Disease List, including HIV and AIDS, plus 14 non-CDL conditions. The guide does not name the 14 additional conditions, so ask for the list before you assume yours is on it.

You register through your nominated GP, not through a form you fill in yourself. Medication is only covered once the beneficiary is registered on the chronic care programme by that GP, and then only as per the medication formulary. Registration is managed by Mediscor: ChroniLine 0860 119 553 or preauth@mediscor.co.za.

Prescribed Minimum Benefits are covered in full as authorised on both options, in terms of section 67(1)(g) of the Medical Schemes Act, including emergency stabilisation. PMBs cover any emergency medical condition, the 270 conditions in the Diagnosis Treatment Pairs and the 27 chronic conditions. On the Primary Option that cover is delivered in state facilities. That is the most important sentence on this page for anyone comparing Primary against a cheap hospital plan elsewhere.

The guide is direct about the medicine formulary: the majority of covered medicines are generics, and if a patient insists on a more expensive alternative the member pays the additional cost directly to the pharmacy. Vitamins, laxatives and proton pump inhibitors are named as commonly requested medicines the scheme does not cover.

• Primary Option. Confinement in a private hospital, covered to a maximum of R30 870. Pre-authorisation must be obtained in the second trimester of pregnancy. Antenatal care runs through your nominated GP. Antenatal scans are limited to two obstetric sonars per pregnancy under the radiology benefit.
• Comprehensive Option. Confinement at any private hospital, subject to pre-authorisation and scheme protocols. No rand cap is published.
• A birth or legal adoption must be reported within 30 days, through your employer's human resources department or the Enablemed call centre, so that the child is registered and the correct contribution is charged.
• The guide publishes no separate benefit for neonatal intensive care, no antenatal consultation count and no postnatal benefit on either option. Where those are Prescribed Minimum Benefits they are covered, and on Primary they are covered in a state facility.
• Contraceptives and contraceptive devices are excluded on both options. Infertility treatment is excluded except where PMB rules apply.

On Primary, the R30 870 confinement limit is a private hospital benefit sitting inside an option that otherwise sends you to a state hospital. If a delivery becomes complicated and the bill runs past R30 870, the guide does not say what happens next. Ask, in writing, before the second trimester authorisation.

Oncology appears in the 2026 guide only under the Comprehensive Option's auxiliary benefits, in three lines:

• Chemotherapy, radiotherapy, radiology, related consultations and pathology are limited to PMB level of care as authorised in terms of the ICON treatment plan.
• No benefit for biologicals.
• No benefit for brachytherapy materials.

There is no rand limit, because there is no benefit above the statutory minimum to limit. PMB oncology cover is real cover, and it is what the law requires of every scheme, but it is a floor rather than a plan feature. Targeted and immunotherapy treatments are largely biological medicines, and those are excluded by name.

On the Primary Option the guide publishes no oncology benefit at all. PMB oncology applies by law, delivered in a state facility, on referral and with pre-authorisation.

If someone in your household has been treated for cancer, or is at high risk, this is the benefit to compare against other schemes before anything else. Several open schemes at a similar family contribution publish an oncology limit in the hundreds of thousands of rand and cover biologicals with a co-payment.

• Comprehensive Option: clinical psychology limited to 8 consultations per family per year, subject to referral from your nominated GP and pre-authorisation. That is a family limit, not a per-person limit, so a household of four shares eight sessions.
• The 2026 guide states these are paid "at agreed 2025 rate". A 2026 document quoting a 2025 rate is either a deliberate rate freeze or an editing error carried over from last year's guide. Confirm the rate with the scheme before your first session, because the difference is yours.
• Primary Option: no psychology benefit is published. Cover is limited to what the Prescribed Minimum Benefits require, in a state facility. The PMB list includes major mood disorders, schizophrenia and bipolar mood disorder, but not most anxiety and adjustment disorders.
• Psychiatry is not listed separately on either option. On Comprehensive a psychiatrist is a specialist and needs a GP referral and pre-authorisation. On Primary a psychiatrist is a state hospital specialist on a PMB basis.
• The guide names no employee assistance programme, no counselling line and no mental health day-to-day benefit.

Both options run dentistry through the same gate: an accredited dentist or dental therapist, who must obtain authorisation from Dental Information Systems on 0860 104 925 before treating you.

The Primary Option is explicit: "There is no benefit for specialised dentistry or dentures." On Comprehensive, R4 420 per family per year has to stretch across root canals and all periodontal treatment for every person on the membership. One molar root canal and crown will normally use most of it.

• Primary Option: R1 180 per beneficiary every 24 months. That single limit has to cover the eye test, the frames and the lenses together.
• Comprehensive Option: R3 270 per beneficiary every 24 months, on the same basis, and it includes multifocal lenses and contact lenses.
• Optometry must be pre-authorised through the call centre on 0860 002 400 before the appointment, on both options.
• Cover is provided only where it is necessary for correcting significant visual impairment, and lenses require a refraction error of 0.5 dioptre or more. A mild prescription may not qualify.
• Replacement of lost spectacles is not covered on either option.
• The benefit runs on a 24-month cycle per beneficiary, not a calendar year, so check your own last claim date rather than assuming January resets it.

That is the complete published list. Makoti does not publish a savings account, a threshold benefit, a wellness or rewards programme, a travel benefit, an out-of-hospital MRI or CT benefit, a scope benefit, an assisted reproduction benefit or a palliative care benefit on either option.

These exclusions apply to Primary and Comprehensive alike, unless the cost forms part of a Prescribed Minimum Benefit.

• Treatment of obesity and its direct complications.
• Anything not medically indicated, and unproven or experimental treatment.
• Wilfully self-inflicted injuries, and injuries from professional sport and speed contests.
• Hire of medical, surgical and other appliances, and surgical stockings.
• Services from anyone not registered with the Health Professions Council, the South African Nursing Council or the South African Pharmacy Council.
• Recuperative holidays, frail care and convalescence.
• Dental extractions for non-medical purposes, and gold inlays.
• Cosmetic and reconstructive surgery, treatment or appliances, including nasal and breast reconstruction unless medically indicated.
• Employer-initiated medical examinations and mass inoculation of employees.
• Injuries where another party is responsible, such as Road Accident Fund or Workmen's Compensation claims.
• Roaccutane and Retin A for skin conditions.
• Contraceptives and contraceptive devices.
• Member travelling expenses, missed appointment fees, and elective after-hours consultations.
• Pathology tests for allergies.
• Infertility treatment except under PMB rules.
• Medicines not registered with the Medicines Control Council, toiletries, home remedies, alternative medicines, bandages and aids, patented foods including baby foods and milk substitutes, slimming preparations, tonics, nutritional supplements, herbal remedies, vitamins and mineral supplements.

There is no international benefit. The guide states that cover is for healthcare services rendered within the borders of South Africa.

If you are involved in a motor vehicle accident, the scheme will pursue a claim against the third party for the medical expenses it paid. To let that happen, you or your dependant must complete an Accident Report form and supply all supporting documentation the scheme asks for.

Injuries where another party is responsible for the costs, including Road Accident Fund and Workmen's Compensation matters, are on the exclusion list. In practice the scheme pays and then recovers, but the co-operation obligation is on you. Do not delay the Accident Report form, because the four-month claim submission rule still applies to the underlying accounts.

• Makoti is classified as an open scheme on the Council for Medical Schemes register, which means membership is not restricted to the employees of one employer. It has employer groups on the book and it takes individual households.
• Dependants allowed are a spouse or partner, biological children, adopted children and immediate family. Direct family members who depend on the member for family care and support are also eligible.
• Children stay on as child dependants until they become employed or turn 21.
• After 21 a child may remain as an adult dependant, at adult dependant rates, up to age 25, on proof of admission and registration as a student at an accredited institution. That step costs real money: on the top Comprehensive band it moves a dependant from R1 346 to R3 546 a month.
• Third generation babies, meaning grandchildren, are not eligible for membership.
• Adding an adult dependant triggers underwriting in terms of the Medical Schemes Act.
• You may not belong to more than one medical scheme.

The 2026 member guide does not publish waiting periods or late-joiner penalties. All it says is that "the Scheme will apply underwriting to all new members as allowed by the Regulations to the Medical Schemes Act", and that adding an adult dependant triggers underwriting on the same basis.

What the Act allows an open scheme to apply, which is therefore the ceiling on what Makoti can impose:

At 75%, a penalty would add R905 a month to a top-band Primary principal member's R1 207, and R3 103 to a top-band Comprehensive principal member's R4 137. A late-joiner penalty is permanent and never falls away.

• You may change option once a year, at the end of the year, with the change effective from 1 January. The option change form must reach Makoti by the cut-off date given in the year-end communication.
• There is no mid-year option change. If your circumstances change in March, you carry the option you chose until the following January.
• You change your nominated GP by completing a Doctor Choice Form. The guide does not limit how often you may do this, and does not say how long the change takes to take effect.
• Report any change to your membership status through your employer's human resources department: a birth or legal adoption within 30 days, a change to a dependant's ID number, a death, the removal or addition of a dependant, divorce or marriage, and a change of address.
• A new membership card is issued when dependant details change. Check the card and report mistakes, because the details on it decide what you pay.

• Everything needs pre-authorisation. The guide says so in a boxed note: "All services are subject to pre-authorisation and clinical protocols." The 24-hour line is 0860 00 24 00.
• Specific pre-authorisation routes: hospital admissions and optometry through the call centre, dentistry through Dental Information Systems on 0860 104 925, chronic medicine through Mediscor on 0860 119 553, ambulances through APA on 0860 102 214. Maternity is authorised in the second trimester.
• Experienced risk managers review all hospital admissions.
• The four-month rule. It is the member's responsibility to make sure accounts reach Enablemed. Accounts received more than four months after the service date will not be paid, and become the member's own debt. Check your statements monthly rather than assuming your doctor submitted.
• Take your Makoti membership card and your ID document to every appointment. Lending the card to an unregistered person is fraud and can end your membership.

Makoti publishes a full four-stage route, which is more than most schemes of its size do.

1. Complain to the scheme, by phone on the dedicated complaints number 011 208 1000 or in writing. Call centre agents assist immediately where they can. Anything unresolved by phone, and anything in writing, gets a written response within 30 days of receipt.
2. Escalate to the Fund Manager if you are not satisfied. Email escalations@makotihealth.co.za, or ask the agent to transfer you to the Senior Client Services Manager or the Fund Manager. The guide requires escalations to be accompanied by supporting evidence of non-delivery.
3. Disputes committee. Any dispute between a member, prospective member, former member or a person claiming through such membership and the scheme must be referred by the Principal Officer to a disputes committee appointed by the Board of Trustees. The Principal Officer convenes a meeting on not less than 21 days' written notice, stating date, time, venue and particulars. Both parties have the right to be heard in person or through a representative.
4. Appeal to the Council for Medical Schemes. An aggrieved person may appeal to the Council against the disputes committee's decision. The appeal must be in the form of an affidavit, directed to Council, and furnished to the Registrar no later than three months after the date the decision was made. The guide gives the CMS complaints address as complaints@medicalschemes.com.

You may contact the Council at any stage. Its complaints line is 086 111 3267 and its switchboard is 012 431 0500, both taken from the scheme's own contact page rather than from the 2026 guide.

No. The 2026 member guide names two options, Primary and Comprehensive, and nothing else. "Makoti Health Plan" appears only in a 2020 Mediscor pharmacy circular that used the older composite name "Medical Scheme Makoti Health Plan of The Good Hope Medical Aid Society". If a broker quotes you a Makoti Health Plan, ask which of the two current options they mean.

No, it is an open scheme. It is classified OPEN on the Council for Medical Schemes register and in the 2012 Government Gazette register of medical schemes, and its own Competition Commission submission describes it as an open medical scheme founded in 1976. Anyone may apply, whether through an employer group or as an individual household. Underwriting still applies.

Only for maternity. The guide states that on Primary, services are accessed in state hospitals only, and Prescribed Minimum Benefits are covered there in full as authorised, including emergency stabilisation. The single exception is confinement in a private hospital, covered to a maximum of R30 870 with pre-authorisation in the second trimester. Every other planned admission on Primary is a state hospital admission.

Because Makoti prices by income band and the first Primary boundary is very steep. A principal member earning R7 900 pays R438. At R7 901 the same member pays R977, a rise of R539 a month for one rand of income, with identical benefits. The adult dependant rate goes from R438 to R805 and the child rate from R295 to R360 at the same point. Ask the scheme in writing which income it uses, whether overtime and commission count, and how often it re-tests.

No. On both options you nominate one general practitioner, and Enablemed contracts with that doctor. The guide says that will then be the preferred GP you are able to consult, except in emergencies. That GP also controls referral to specialists, radiology and pathology. You can change GPs by completing a Doctor Choice Form, but you cannot use a second doctor at will.

On the Comprehensive Option, chemotherapy, radiotherapy, radiology, related consultations and pathology are limited to Prescribed Minimum Benefit level of care, authorised under the ICON treatment plan, with no benefit for biologicals and no benefit for brachytherapy materials. On the Primary Option no oncology benefit is published at all, so cover is PMB only in a state facility. Most targeted cancer therapies are biological medicines, and those are excluded by name.

R1 180 per beneficiary every 24 months on Primary and R3 270 per beneficiary every 24 months on Comprehensive. Both limits have to cover the eye test, the frames and the lenses together. Comprehensive includes multifocal and contact lenses. You need pre-authorisation on 0860 002 400 before the appointment, your refraction error must be 0.5 dioptre or more, and lost spectacles are not replaced.

Very little. Pathology is limited to eleven named tariff codes: liquid based cytology, cervical or vaginal smears, quantitative glucose, glycosylated haemoglobin, haemoglobin estimation, platelet count, HIV Elisa, RPR, ABO grouping, Rh grouping and total white cell count. Radiology is limited to a chest X-ray, suspected fractures of extremities and two obstetric sonars per pregnancy. Everything a doctor might order beyond those lists is your own cost unless it is a Prescribed Minimum Benefit.

The 2026 guide does not say. It states only that the scheme applies underwriting to all new members as allowed by the Regulations to the Medical Schemes Act. The Act permits an open scheme to apply a general waiting period of up to 3 months, a condition-specific waiting period of up to 12 months on a pre-existing condition, and a permanent late-joiner penalty of 5% to 75% for applicants aged 35 and over without proof of prior South African scheme cover. Get the scheme's answer for your own application in writing and check it appears on your acceptance letter.

Because of the four-month rule. The guide makes it the member's responsibility to ensure accounts are submitted to Enablemed, and states that accounts received more than four months after the service date will not be paid in terms of the scheme rules and become the member's responsibility. If a practice submits slowly, the loss is yours. Check your statements every month rather than assuming the account went through.

No. Option changes happen once a year, at the end of the year, effective 1 January. The option change form must reach Makoti by the cut-off date given in the year-end communication. If your health or income changes in March, you stay on the option you chose until the following January.

Four stages. Complain to the scheme by phone on 011 208 1000 or in writing, and unresolved or written complaints get a written answer within 30 days. Escalate to the Fund Manager at escalations@makotihealth.co.za with supporting evidence. If that fails, the Principal Officer refers the dispute to a disputes committee appointed by the Board of Trustees, convened on at least 21 days' written notice, where you may be heard in person or through a representative. You may then appeal to the Council for Medical Schemes by affidavit within three months of the decision. The Council can be contacted at any stage on 086 111 3267.