Hospital Plans & Cover Options

What is a Hospital Plan?

First things first, we’ve got to understand what a hospital plan is.

It’s a form of medical aid governed by the Medical Schemes Act and regulated by the Council of Medical Schemes in South Africa. But it's one that doesn't have a savings account or day-to-day benefits like a more comprehensive medical aid plan does. It only covers you for the medical costs involved in hospital stays. It will pay for the bills issued by the hospital itself (like your food, bed, and in-hospital medication), as well as specialists' fees, like anesthesiologists, gynaes, and orthopaedic surgeons (but only up to a certain amount—we’ll talk a little more on this later). But is it the right option for everyone? Probably not, as no two people have the same healthcare needs or bank balance!

Most procedures will be approved for private hospital cover on both a full medical aid or a hospital plan, as long as they are clinically required, although this does vary depending on your plan. There are exceptions to these rules, of course. For example, some hospital plans will cover elective c-sections or joint replacements. Generally speaking though, these types of hospital expenses will have limits and cover shortfalls.

Then there’s the sub-limits. Certain common procedures in-hospital often have limits, like dentistry or back and neck procedures.

What About Specialist Fees?

Hospital plans pay for doctors' fees in-hospital, but usually only up to a certain amount. Depending on the plan you're on, this could be 100%, 200%, or 300% of the medical aid rate or tariff.

Network plans can greatly reduce your costs, but if you already have a healthcare professional at a specific hospital and they're not on the scheme's network list, you'll need to make co-payments if you continue to use them. But either way, you do still get to have private hospital cover.

What is a Network Plan?

This is when your medical scheme specifies the hospital facilities and doctors you can visit. This means you can't see just any doctor at any hospital for a planned procedure if you want to avoid a non-network co-payment. Note, however, that all medical aids must provide cover for emergency treatments at any hospital, like a heart attack or a stroke. So, for example, if you choose to have your baby at a hospital that is not on your medical aid plan network, you will be charged with a high penalty co-payment by the hospital. Some comprehensive gap products cover one or two penalty co-payments when you go to a hospital out of the network. It’s just as important to understand the benefits offered by your gap cover as it is to understand your medical aid!

Network plans can greatly reduce your costs, but if you already have a healthcare professional at a specific hospital and they're not on the scheme's network list, you'll need to make co-payments if you continue to use them. But either way, you do still get to have private hospital cover.

Medical aids actually name their network hospital products specifically, but how are we to know what the product names mean? Here’s a bit of help with some of the larger medical aid network plan names:

We hope these naming tips have helped😊. Remember, if you’re surprised that you’re on a network plan after reading this, make sure that you know the hospitals in your network and what the co-payment is if you choose to use an out of network hospital—and make sure you have a comprehensive gap policy to cover you.

Private hospital expenses can be sky high—more than the average Joe or Jane can afford. A hospital plan could be the answer if you're looking for something cheap that will still give you comprehensive in-hospital cover should you become injured or ill. Ready to find your perfect affordable hospital plan?