What is a medical scheme hospital network
Network plans within medical schemes in South Africa are structured to provide members with access to a specified group of healthcare providers, including hospitals, doctors, specialists, pharmacies, and other healthcare facilities. These plans are designed to control costs while ensuring quality healthcare services for members.
Here’s why network plans are used by medical schemes and insurers in South Africa:
- ✅ By contracting with specific healthcare providers, medical schemes can negotiate discounted rates for services. These negotiated rates help to control costs for both the scheme and its members.
- ✅ By creating a network of trusted providers, the scheme can ensure that its members receive high-quality medical services. Providers within the network are often subject to performance evaluations and quality assessments to maintain standards of care.
- ✅ Network plans often involve streamlined administrative processes for members. This can include easier appointment scheduling, pre-authorization for certain procedures, and simplified billing and claims processing.
- ✅ Network plans often include access to a wide range of specialists and sub-specialists, ensuring that members have timely access to the expertise they need.
When to Choose Network Plans
When deciding whether a network plan is a suitable option for your needs, consider the following factors:
Coverage and Provider Network
Evaluate the extent of coverage offered by the network plan, including the range of healthcare services and the network of providers available. Make sure that your preferred healthcare providers, including doctors, specialists, hospitals, and pharmacies, are included in the network.
Costs and Affordability
Assess the cost structure of the network plan, including premiums, co-payments, deductibles, and co-insurance. Compare these costs with your budget and financial situation to determine affordability. Consider whether the plan offers value for money in terms of the coverage provided.
Quality of Care
Research the quality of care offered by the healthcare providers within the network. Look for information on provider credentials, reputation, patient satisfaction ratings, and clinical outcomes. Ensure that the network plan prioritizes high-quality care and patient safety.
Access to Specialists
Determine whether the network plan provides access to the specialists and sub-specialists you may need for your healthcare needs. Consider the availability of specialized services, such as mental health, maternity care, chronic disease management, and emergency care.
Location
Consider the geographic accessibility of the network plan, particularly if you live in a rural or remote area. Make sure that there are healthcare providers within the network located conveniently to your home or workplace. Evaluate the availability of emergency services and urgent care facilities.
Cover for Pre-existing Conditions
Check whether the network plan covers pre-existing medical conditions or imposes waiting periods or exclusions for certain conditions. Ensure that the plan meets your specific healthcare needs, especially if you have existing health conditions or require ongoing medical treatment.
Flexibility and Choice
Assess the flexibility and freedom of choice offered by the network plan. Determine whether you are required to select a primary care physician or obtain referrals for specialist care within the network. Consider whether the plan allows you to seek care outside the network if needed and the associated costs.
Limits and Exclusions
Review any coverage limits, exclusions, or restrictions imposed by the network plan. Understand what services and treatments are covered, as well as any limitations on coverage, such as annual maximums, waiting periods, or restrictions on experimental treatments or elective procedures.
Dis-Chem Health Network Hospitals
🌍 Johannesburg and Pretoria:
- Mothwa Med-Step Clinic
- Brooklyn Surgical Centre
- Pretoria East Eye Institute
- Intercare Subacute Hospital Hazeldean
- Intercare Subacute Hospital Hazeldean Irene
- Medicure 24 – Maternity Unit
- Morehill Clinic
- Advanced East Rand Day Hospital
🌍 Mbombela:
- RH Phodiclinic
🌍 Bloemfontein:
- Hillandale Healthcare Centre
- Care Cure Victoria Gardens
🌍 Kimberley:
- Andalusia Clinic
🌍 Komani:
- Nurture Care Cure Queenstown
🌍 East London:
- East London Private Hospital
- East London Plastic and Reconstructive Surgery
🌍 Gqeberha (2)
- Life Isivavana Private Hospital
- Nuture Aurora Physical Rehabilitation Centre
🌍 Pietermaritzburg:
- St Mary’s Step-Down
Dis-Chem Health Network Plans
Hospital Accident Cover
Please note that the plans above constitute medical insurance, and are not network plans as offered by medical aid schemes.
Network Hospital Exceptions
If there are no network providers near where you reside, you can phone the Dis-Chem call center at 0861 029 892 and they will look for providers in the region. If they are unable to reach an agreement, an arrangement will be formed to pay your doctor up to a cost limit, subject to the available limits of your selected plan.
Alternatively, you can replace your doctor’s (GP) visits with a virtual consultation. You can schedule a Virtual Consultation using the Mobile App or our website.
Conclusion
Network plans offer a balance of benefits and drawbacks worth considering when selecting healthcare coverage. On the positive side, they often provide cost savings through negotiated rates, streamline access to high-quality care, and offer a wide range of specialists. Added to this, managed care elements can enhance efficiency and coordination.
However, limitations in provider choice, potential out-of-network costs, and geographic restrictions may present challenges for some individuals.
Ultimately, weighing these pros and cons against individual healthcare needs and preferences is crucial in making an informed decision about whether a network plan aligns with your healthcare requirements.
