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In South Africa, a hospital plan is a type of medical product that falls under the Medical Schemes Act of 1998 and the authority of the Medical Schemes Council. It is designed to specifically cover the costs of in-hospital medical treatment and related expenses. It is an affordable healthcare option that provides financial protection against the high costs of hospitalisation, without offering comprehensive day-to-day medical benefits offered by medical aid plans. Here is a comprehensive explanation of how hospital plans work in South Africa.
A hospital plan provides coverage for medical expenses incurred during hospitalisation. It typically includes the costs of accommodation, surgeries, procedures, doctor’s fees, and prescribed medication while you are admitted to the hospital. The coverage is limited to in-hospital treatment and does not generally extend to out-of-hospital medical services, such as general practitioner visits or prescription medication for chronic conditions.
It is also important to consider if and what limits various hospital plans have in place. Just like medical aid plans, hospital plans can limit the amount of hospital expenses covered. They may for example only pay 100% of the medical fund rate while the actual costs charged by the hospital are closer to 300%. Gap cover can be taken out to help cover any such shortfalls in the hospital plan’s cover.
Unlike comprehensive medical aid plans, a hospital plan does not offer day-to-day medical benefits, such as consultations with doctors or routine medical tests. Therefore, individuals with a hospital plan would need to pay out-of-pocket for non-hospital medical services.
Network of Providers
Hospital plans often have a network of designated hospitals and specialists where the plan’s benefits are maximised. These designated service providers are typically contracted with the medical insurer to provide services at agreed-upon rates. Choosing these network providers can help minimise co-payments or out-of-pocket expenses for policyholders.
Just like medical aids, hospital plans may also have waiting periods before certain benefits become accessible. Common waiting periods include those for pre-existing medical conditions and maternity benefits. It is essential to be aware of the waiting periods and consider them when choosing a hospital plan to ensure you are covered if needed. Considering that waiting periods are imposed when a member takes out the hospital plan, it is advised to not change from one provider to a different provider if there is not a good reason to do so.
Prescribed Minimum Benefits (PMBs)
Hospital plans, like other medical aid plans, are required to provide Prescribed Minimum Benefits (PMBs). PMBs are a set of defined medical conditions and treatments that medical schemes are legally obligated to cover in full, regardless of the plan you choose. PMBs ensure that policyholders have access to essential medical treatments and emergency care.
Hospital plans are generally more affordable than comprehensive medical aid plans because they offer limited benefits. The premiums are lower since they cover only in-hospital treatment and exclude day-to-day medical expenses.
Some hospital plans may offer limited additional benefits, such as emergency medical transportation, trauma counselling, or accidental death cover. However, these additional benefits can vary among different plans and need to be an important consideration when choosing which hospital plan suits your situation best.
Hospital plans may have specific exclusions, which are medical conditions or treatments not covered by the policy. Policyholders should carefully review the exclusions to understand what is not covered under the plan.
A hospital plan is a cost-effective option for individuals seeking essential coverage for in-hospital medical treatment. While it does not provide comprehensive day-to-day benefits, it offers valuable financial protection against the significant expenses associated with hospitalisation. As with any medical product, it is crucial to compare different hospital plans, review the terms and conditions, and choose a plan that aligns with your healthcare needs and budget. Consulting with a licensed financial advisor or broker can also be beneficial in making an informed decision about your healthcare coverage.