Hospital plans in South Africa offer a practical and cost-effective solution for individuals and families who require access to essential healthcare services. In light of the steady decline in public sector healthcare and the nation’s economy, the need for assistance with treatment costs has never been greater.
Medical schemes met this acute need with the hospital plan, a limited product designed to address gaps in public healthcare by meeting a scheme’s members’ needs when receiving private treatment as an inpatient. It’s important to note that the focus of these plans is on those expenses incurred whilst the member is hospitalised. Depending on which plan one chooses, it might not make any provision for subsidising the member’s day-to-day expenses, or it could address their outpatient medical costs to differing degrees in keeping with the monthly premium price.
Hospital plans were initially intended to assist young, unmarried people with good general health to cope with the unexpected and potentially crippling cost of surgery and, perhaps, weeks in a hospital bed following an accident or medical emergency. However, in recent years, many South African families have been struggling financially and looking for ways to economise. Consequently, some schemes have extended the benefits of a typical entry-level hospital plan to create products that more fully meet their members’ needs in a drive to provide affordable access to private healthcare for all.
Some Considerations When Selecting Hospital Plans
Currently, 18 schemes operating in South Africa are open to all. Each offers a range of products, usually starting with a “bare bones” option that offers unlimited inpatient coverage only. When making your choice, you should pay attention to the following points:
- Affordability: Premiums are payable monthly, and failure to pay could result in loss of cover. If you are attempting to compare products from different schemes, don’t be tempted to opt for the cheapest. Instead, check out any that fall within your budget to see which offers all the cover you need and the best value for money.
- Limits to cover and exclusions: Terms and conditions are applied to all medical aid products. Because, by definition, hospital plans offer limited cover compared to comprehensive products, it is crucial to check that the benefits offered are in line with your known healthcare needs. Note that some plans may have specific exclusions, and these could leave some of your needs unmet.
- Outpatient benefits: If you are willing and able to pay for any medical expenses incurred as an outpatient, that’s fine. However, perhaps you need support with costs like GP and specialist visits, optometry, dentistry or prescribed and over-the-counter medication. In that case, some hospital plans may provide for some or all of these contingencies.
- Designated service providers: Although the Department of Health sets tariffs for every procedure or item relating to healthcare, these relate to state-funded service and the private sector is not bound by them, often charging twice or three times the recommended sums. Some schemes like KeyHealth Medical have recruited a network of clinics, specialists, pharmacists and laboratories that agree to moderate their tariffs to ensure members’ claims are settled in full or will require just a modest co-payment.
- Prescribed minimum benefits: The Medical Schemes Act of 1998 requires all medical scheme products to cover certain specified contingencies in and out of hospital, including 26 chronic illnesses.
- Waiting periods: All medical schemes are permitted to apply waiting periods in certain circumstances to avoid abuse of their services. These restrictions should, therefore, not influence your choice, but it is essential that you understand how they will affect you. These are of two types as follows:
- General: First-time members and their dependents will be unable to claim for any medical expenses incurred during the first three months of their membership. Anyone not covered by another scheme during the three months before they applied will also be subject to this restriction.
- Specific: Members with any pre-existing condition will not receive payments for services related to that condition during the first 12 months of their membership.
- Late joiner penalty: While all members are usually charged the same for specified hospital plans, anyone aged 35 or over who joins a scheme for the first time will pay progressively more per month depending on the number of years without cover and their overall health.