Hospital Plan Insurance as Part of Medical Aid Schemes
Hospital plan insurance on its own can refer to one of two concepts:
- Insurance that pays out to the hospital when the member is hospitalised.
- Payment of specific amounts into the member’s bank account for every day in hospital.
The normal hospital plan works much like a medical scheme, but excludes out-of-hospital and day-to-day benefits. Most of these plans only start paying on the second or third day of hospitalisation and pay limited amounts.
The second option is where the hospital plan insurance provider pays a set amount into the member’s bank account irrespective of the reason for hospitalisation. The services rendered by the hospital are not considered. The plan is rather an income insurance to provide the member with income during the period of hospitalisation. The amounts paid can be used for payment of medical costs or for any other purpose.
Hospital Plan Insurance as Part of a Medical Aid Scheme
The hospital plan as part of a medical aid scheme such as KeyHealth is not a cash pay-out plan and also doesn’t work the same as normal insurance. The amounts are payable to the designated service provider according to the benefits structure of the member. Pre-authorisation must be obtained for hospitalisation and specific procedures. Payment however, is applicable from day one of hospitalisation and includes emergency care. Most medical aid schemes include hospital plans and day-to-day benefits. This ensures that should a member or one of the beneficiaries be hospitalised that the services rendered will be covered irrespective of whether the member has used day-to-day benefits to the maximum.
Authorisation for Hospitalisation
Members must obtain authorisation for hospitalisation prior to admittance to the designated hospital. If not possible because of an emergency situation, a family member, friend or the hospital can contact the medical aid provider to provide the necessary information. Without such, benefits will not be paid.
Various Levels of Cover
Although all our benefit packages include hospital plans the payment limits differ as well as services covered. It is essential to review the hospital plans for each of the packages to determine which one will be best for you and your family.
If you or one of your family members suffer from a chronic condition or disability and require regular hospitalisation, we recommend that you consider one of the more comprehensive packages such as Gold or Platinum. Silver is the middle package for the average and relatively healthy family. Essence and Equilibrium are perfect starter or basic packages and well-suited for smaller families, young people, and people with optimal health.
The reference prices are the maximum amounts payable by the Scheme for drugs or similar drugs as listed in the Condition Medicine List for the particular condition. The prices vary according to the benefits package opted for. It is your choice whether you want to pay in the difference between the maximum price that the Scheme is willing to pay and that asked for by the service provider. You can select a generic or cheaper alternative or you can opt to pay in the difference. We review the reference pricing once a year.
Prescribed Minimum Conditions
The Medical Schemes Act No. 131 of 1998 regulates the prescribed minimum conditions. In essence, it means that specific conditions treatable in hospital must be covered by any medical scheme. A list is available for such conditions, but note that it refers to treatment in a state hospital. You can find the list at the Council of Medical Schemes.
The cost of diagnosis and treatment of all emergency medical conditions and a limited set of +- 270 medical conditions, including 25 chronic diseases must be covered by a medical scheme in state hospitals.
Designated Service Providers are approved medical care institutions and where the prescribed minimum benefits are covered. We have appointed DSPs from the New National Hospital Network for specific packages and state facilities for all options.
KeyHealth is an open medical aid scheme and anyone can thus become a member. Our tariffs are exceptionally well-priced and we offer several levels of cover with all options including specific hospital plans for maximum peace of mind.