Medical aid and dental implants in South Africa

Why cover varies so much

South African medical schemes set their own dental benefits, and those benefits differ by scheme, by plan within a scheme, and from year to year. Most schemes publish an annual benefit guide that explains what dental treatment they fund and how. Implant treatment is often handled differently from basic dentistry such as check-ups and fillings, and different stages of implant treatment may be funded in different ways, or not at all.

Because of that, the only reliable answer about your cover comes from your own scheme, for your own plan, for the specific procedures in your treatment plan.

Stages may be funded differently

An implant plan contains several separate procedures: imaging, any extraction or grafting, placing the implant, the abutment, and the crown, bridge or denture on top. A scheme may fund some of these and not others, may fund them from different benefit pools, or may set limits. Hospital or theatre treatment may fall under different rules again, and may need separate pre-authorisation.

For example, Discovery Health Medical Scheme's 2026 dental benefit guide describes separate benefits for basic dental treatment, for severe dental and oral surgery, and for basic dental trauma. It defines basic dental trauma as a sudden, unanticipated impact injury to the teeth and mouth, including extraction and a replacement implant after the loss of teeth in an accident or injury that occurred in the preceding 30 days. That is one scheme's definition for one benefit year; other schemes and plans differ. [CONFIRM: any further scheme-specific figures before they are published]

Pre-authorisation

Many schemes require pre-authorisation for some dental procedures, for hospital admission, and for treatment funded from specific benefits. Pre-authorisation is not a promise of payment in full; it confirms what the scheme will consider funding, under what conditions. Ask your scheme whether any part of your plan needs it, and leave time for the process before your treatment date.

Procedure codes

Practices bill medical aids using procedure codes, and schemes decide cover by code. Ask the practice for the codes in your treatment plan, then give those codes to your scheme and ask what it will fund for each, at what rate, and from which benefit. That turns a general question about "implant cover" into a specific, answerable one.

Gap between the fee and the scheme rate

Schemes usually pay at their own rate for each code, which may be lower than the fee the practice charges. The difference, sometimes called a shortfall or co-payment, is usually yours to pay. Ask the practice what its fees are for each code, and ask the scheme what it will pay, so you can see the difference before treatment starts.

Questions to ask your scheme

• Which of these procedure codes are covered on my plan this year?
• From which benefit is each paid, and what limits apply?
• Is pre-authorisation needed, for which items, and how long does it take?
• At what rate do you pay each code?
• Are hospital or theatre costs treated differently?
• Do any waiting periods or exclusions apply to me?

Questions to ask the practice

• What are the procedure codes for each stage of my plan?
• What is your fee for each code?
• Will I pay you and claim back, or do you bill the scheme directly?
• Will other providers, such as a radiologist, anaesthetist or hospital, bill separately?

Our guide to what influences a dental implant quote explains the items on a plan in more detail.

Frequently asked questions

Related

• What influences a dental implant quote in Johannesburg
• Implant-supported dentures
• Implant assessment
• All-on-4 and full-arch implants