If a comprehensive medical aid is too expensive for your budget, why not consider a hospital plan that covers you for hospital costs and treatment for chronic medical conditions?
Medical aid is expensive, and the monthly contributions are increasing more than average salaries.
Hospital stays, however, tend to be our biggest medical expense, so a hospital plan might be just what the doctor ordered. You can make sure your most expensive healthcare bills are taken care of and you and your family are assured of the medical treatment you need in case of an emergency. You’ll have to pay for some expenses yourself such as visits to your GP or dentist, but if you keep some savings for these expenses, hospital plans can be a good option.
We’ve looked at some of the cheapest hospital plans in South Africa and compared them to show you what they offer. We’ve also explained some of the terms and jargon used in the medical aid world below the table.
The premiums we compared below are for a family of four (two adults and two children) for 2019. We compared only the most common benefits on each scheme and more details on what the schemes offer are available on their websites. Click here to download the comparison.
Medical aids tend to market hospital plans for the young and healthy, because if you have an illness or condition the out of hospital expenses can add up, and you may get to a point where the amount you have spent from your own pocket is more than the amount you saved in contributions by switching to a hospital plan. You can chat to your financial advisor or medical scheme broker about what option is suitable for you.
Alternatives to hospitalisation
While hospital plans cover hospital and in-hospital costs only, medical aids are very aware of how expensive a hospital stay can be. As a result, some offer out of hospital benefits on hospital plans that cover the costs of certain procedures and care done at a doctor’s rooms as an alternative to a hospital stay.
Medical aids have authorisation policies, which means that when you are undergoing major treatment such as surgery you need to apply for authorisation, so your scheme will cover you at the agreed rate. If you don’t apply for authorisation some schemes won’t cover the full amount. When you apply for authorisation don’t assume it means every cost is covered – ask exactly what procedure and treatment is covered and what is not.
Chronic disease list, formularies and protocols
The chronic disease list is a list of approved medications for PMBs. These medications are sometimes referred to as formularies. Protocols are treatment guidelines. Some medical aid plans will only cover the costs if treatment protocols are followed and approved medications used.
Comprehensive medical aid options and hospital plans
Comprehensive medical aid options cover the cost of a range of in and out of hospital benefits, hospital plans cover in-hospital costs only. Out of hospital benefits are also known as day to day benefits.
Medical aids might not cover the cost of a procedure or treatment in full and require a co-payment or be limited to a set amount. Scans and scopes often have co-payments, but if a scan or scope is for a PMB it should be covered in full.
Disease management programmes
Most medical aids have disease management programmes where you have to register for certain benefits if you have a specific condition such as HIV, diabetes and cancer. If you are diagnosed with a chronic illness schemes are more likely to cover costs of certain treatments in full if you register on these programmes. Some schemes also offer maternity and baby programmes that offer extra benefits such as discounts on baby products.
(See Networks below)
A formulary is a list of approved medicines. Schemes usually cover formulary drugs in full. Non-formulary medicines may require a co-payment or may not be covered at all.
Hospital costs and in-hospital costs
Private hospitals in South Africa don’t employ specialists or doctors so when you stay in hospital you will have an account from the hospital for their fees, including ward and theatre fees, and an account from specialists and doctors who consult while you are in hospital such as anaesthetists and surgeons. It is a good idea to check with your medical aid how they cover both these costs. Hospital plans usually cover them all, but often have additional requirements that you use certain hospitals, doctors and surgeons to qualify for full cover.
Medical aid, medical insurance, gap cover and dread disease cover
Medical aid is offered by registered medical schemes and offers options with different benefits. These benefits include hospital cover, PMB cover (explained below), general healthcare and sometimes preventative screening. Medical aid pays for costs actually incurred either in full or at an agreed rate.
Medical insurance, offered by registered insurance companies, offers a set amount of cover in Rands such as R200 000 or R500 a day in hospital. Medical aids tend to pay doctors and hospitals, medical insurance products pay the life insured.
Gap cover is a type of medical insurance that can pay for amounts your medical aid may not cover.
Dread disease cover is an insurance policy that pays out a lump sum on diagnosis, according to the diagnosis and the amount insured.
Networks and DSPs
If you want to save on your medical costs and medical aid contributions use network options and DSPs - designated service providers.
Medical aids negotiate favourable rates with certain doctors, hospitals and other healthcare providers, which usually means you won’t pay anything out of your own pocket when you consult these doctors and use hospitals in this network. DSPs work in a similar way – they agree on rates and services and medical aid members don’t incur extra costs when using them. Medical aid options that use only network providers and DSPs are cheaper. Networks and DSPs can include private and state hospitals, so if you are worried this limits your choice too much, have a look at who is on the network and who the DSPs are before making a decision.
Prescribed minimum benefits (PMBs) are benefits all medical aids must cover on all options, including hospital plans. They cover 25 chronic conditions such as asthma and diabetes, 270 medical conditions such as HIV and some cancers, and any emergency medical condition.
An emergency is when immediate treatment is needed, and if it is not received there may be serious and lasting damage or loss of life or limb.
You’ll notice the term “100% of scheme rate” quite a lot when looking at medical aid brochures. This is the rate the medical aid has agreed to pay certain healthcare providers such as doctors and hospitals. Medical aids will cover costs at a percentage of this rate for example 100% or 200%, depending on which plan you are on. While these rates are not publicly available, they don’t differ too much across schemes and hospital costs are usually covered in full. However, 100% of the scheme rate is not always 100% of the cost so if you are having a procedure ask your doctor and medical aid what they charge and cover.
Wellness screening and preventative care
Most schemes offer these to all their members at no cost. They include testing for HIV, cholesterol, blood pressure and blood glucose tests, and vaccines and immunisation such as the flu vaccine. Many hospital plans offer these, but some are limited to a Rand amount, number of tests per family or number of tests over a number of years at certain ages.