The Difference Between Medical Aid and a Hospital Plan

Hospital room with three beds.


Are you considering getting a full medical aid or a hospital plan? Whether you're young and healthy, or have a family with more demanding healthcare needs, it's a smart move to understand what type of cover would suit you. However, it can be tricky to decide. Let's take a look at your options and find out which might suit your lifestyle best.


Do I really need a medical aid or a hospital plan?


For many people, the only time they spend money on healthcare is at an annual check-up with the GP. For this reason, they may think they don't need medical cover. However, medical costs are often unexpected and expensive, which is where medical aids and hospital plans come in. From coming down with the flu to being diagnosed with a chronic medical condition to sustaining an accidental injury, everyone has to pay for unforeseen medical expenses at some point. Medical cover can relieve a lot of the stress and uncertainty around paying these bills.


The short answer is, therefore, yes. Everyone, no matter how young or old, can benefit from having cover limited to hospitalisation expenses or a plan that covers both in- and out-of-hospital expenses.


Now that you know that medical cover can help you pay for unexpected medical bills, it's time to decide what kind of cover you want. Two of the basic options are hospital plans and medical aids. Let's take a look at both of these.


What is a hospital plan?

A medical aid hospital plan helps you pay for medical costs that arise if you're hospitalised. Your scheme will pay a specific amount towards your admission, stay, doctors' bills, and other costs incurred. Not all hospital plans are created equally, as some have richer benefits and fewer co-payments, whilst others have stricter rules, exclusions, and limits.


It's important to note that hospital plans only cover you for expenses incurred when you are admitted to the hospital. You'll need to pay for out-of-hospital costs, like visits to your GP and acute medication, yourself. However, all medical aid plans, including hospital plans, are obligated to provide medication cover for a defined list of 25 chronic diseases, even if you are not hospitalised.


Before you're admitted to hospital, you'll need to obtain pre-authorisation from your provider, except in the case of an emergency, when the hospital will arrange admittance with your provider.


What is a medical aid?

A medical aid helps you pay for medical costs in and out of hospital. This is the primary difference between the two types of medical cover. Medical aid schemes will have a set amount they will pay for certain out-of-hospital procedures like doctors' visits, medication, optometry, and dentistry. These benefits vary depending on the type of plan you choose – generally, the more comprehensive the plan, the more you're covered for.


You can add family members to any type of medical aid products, so do thorough research on the plans available; some are best for individuals while others are better suited to families.


All medical aids also cover minimum health benefits irrespective of the level of coverage you sign up for. This includes emergency medical conditions and prescribed minimum benefits, which is a list of 270 conditions and 25 chronic diseases.


What's the difference between a medical aid and a hospital plan?

Medical aids cover a lot more than hospital plans do. A hospital plan covers treatment and medical costs that arise while the insured is booked into hospital, while a comprehensive medical aid plan will cover hospital costs and other private medical needs like specialist consultations, GP visits, and additional tests or procedures.


Here are some hypothetical scenarios to make the differences between the two clearer:


My husband has man flu. I sent him to the general practitioner and she prescribed a cough syrup.

Medical aid: Many medical aids will cover the GP visit and the medication depending on the terms and conditions of your particular plan, as well as your available day-to-day savings.
Hospital plan: Doesn't cover GP visits unless they visit you during a hospital admission.


My elderly mother fell and broke her hip. An ambulance rushed her to the hospital and she is now in surgery.

Medical aid: Your medical aid will offer cover in this situation, although there may be co-payments and exclusions. Read through your medical aid documents or call your provider to find out what terms and conditions may apply. Some plans will only cover you in certain hospitals or for specific procedures.
Hospital plan: Your hospital plan covers in-hospital costs. The same kinds of terms and conditions as above may apply depending on how comprehensive your cover is.


My daughter was just diagnosed with asthma and needs chronic medication.

Medical aid: Legally, all medical aids must cover certain chronic conditions, including asthma. Therefore, your medical aid must pay a certain amount towards the costs of the medication. However, when taking into account your doctor's fees and the specific medications prescribed, there may still be shortfalls that you'll need to cover yourself. Also, be aware that the medical aid may require proof of the condition from your doctor before they will pay, subject to the payment rules of your plan.
Hospital plan: Medical aid hospital plans are subject to the same legal requirements as full medical aids for the defined list of chronic conditions, including asthma. So your daughter would be covered in the same way as above, subject to the same shortfalls and payment rules of your plan.


My wife was involved in a car accident and is in critical condition. They rushed her to the nearest hospital and she is now in ICU.

Medical aid: Your medical aid should cover this, as an emergency procedure is recognised as a prescribed minimum benefit. If your plan has hospital network rules, you'll be stabilised at the nearest private hospital then moved to a network hospital recognised by your plan.
Hospital plan: Same as above.


When to get a hospital plan?

A hospital plan is more affordable than a comprehensive medical aid, so it may be a good option for lower-income or healthier individuals who want access to private healthcare. Medical aid hospital plans also cover the 25 prescribed minimum benefit chronic conditions, so your decision should be influenced by whether you are willing to self-fund other general out-of-hospital expenses instead of paying the higher monthly premium for a comprehensive medical aid.


When to get a full medical aid?

This decision is based on your levels of affordability and overall spend on out-of-hospital expenses. If your out-of-hospital spend is higher than the cost of paying for a full medical aid over a 12-month period, you're better off on a full medical aid. Many products simply have savings account components that cover your out-of-hospital expenses. It's important to remember that this is actually your money and not the scheme paying for these costs.


Are there waiting periods to join a medical aid?


For new members joining any type of medical aid product, your history of cover will determine your waiting periods. For example, if you have been on a medical aid for a period of two years or longer and wish to switch without a break in cover, your new scheme can only impose a three-month general waiting period. If you have not had previous cover or have had breaks in between, the medical aid may impose a three-month general waiting period and a 12-month waiting period on any pre-existing conditions. Medical aids are also able to impose a loading on your monthly rate if you're joining for the first time after the age of 35. This is called a late-joiner penalty and the additional percentage added to the monthly contribution is dependent on your age and the number of years you've been uncovered. The calculation works as follows:


Age upon application (35+ years covered previously) + the number of years the applicant was uncovered. A percentage is used to calculate the penalty:


0 – 4 years uncovered: 5% of total contribution;
5 – 14 years uncovered: 25% of total contribution;
15 – 24 years uncovered: 50% of total contribution; and
25 years or more uncovered: 75% of total contribution.


Think about your budget, your family's health, your medical history, any hereditary family issues, chronic conditions, therapy needs, and also consider pregnancy or the life stage of your family. You can then compare medical aids online to determine which is best for your situation. We've made it easy to look at multiple medical aids side by side so you can make an informed choice. So before you commit, hippo it.


Prices quoted are correct at the time of publishing this article. The information in this article is provided for informational purposes only and should not be construed as financial, legal, or medical advice.


Sources: CMS

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