Hospital Plan vs Medical Aid - A Beginners Guide
The difference between a hospital plan and a medical aid in South Africa revealed.
We tested them side by side and verified medical aids versus hospital plans.
This is a complete guide to the difference between medical aids and hospital plans in South Africa.
In this in-depth guide you’ll learn:
- What is a Medical Aid?
- What is a hospital plan>
- What do hospital plans cover in South Africa?
- What is limited covered medical aid?
- How to choose between hospital benefits and medical aids?
So if you’re ready to go “all in” with the difference between hospital plans and medical aids in South Africa, this guide is for you.
Let’s dive right in…
Hospital Plan vs Medical Aid – A Beginners Guide Summary
Introduction
👉 Your membership payments for the medical plan have been increased once more. Is it something that’s worth your time, or should you consider getting a hospital plan instead?
👉 This is a subject that is on the minds of a great number of younger people who are in generally good health, particularly those who are struggling to make payments on a mortgage or a vehicle loan in addition to their other obligations. Or those individuals who have exhausted the funds in their Health Savings Accounts by the time the middle of the year rolls around.
👉 Are you thinking about enrolling in a full medical aid programme or purchasing a hospital plan? Whether you are still young and healthy or have a family with more demanding healthcare demands, it is a good decision to understand what type of coverage would be appropriate for you. Nevertheless, making a choice can be difficult. Let’s have a look at your choices and figure out which one would be the most appropriate for your way of life.
Do you need medical aid or is a hospital plan enough?
👉 When a visit to a physician once a year is the one and only occasion on which you spend money on health care, you may believe that you do not require medical coverage. Unfortunately, medical bills are notorious for being unforeseen and prohibitively expensive, which is where medical aids and hospital plans come into play.
👉 Everyone will, at some point in their lives, be forced to pay for unanticipated medical costs, whether it’s because they get the flu, are diagnosed with a persistent medical condition, or experience an injury through no fault of their own.
👉 Having medical coverage can alleviate a lot of the anxiety and uncertainty that comes with the responsibility of paying these payments.
👉 Therefore, no matter how old or young you are, people of any age can benefit from having either coverage that is restricted to hospitalisation expenses or coverage that extends to both in-hospital and out-of-hospital expenses.
👉 You need to make a decision regarding the type of medical coverage you desire now that you are aware that having medical coverage can assist you in paying for unforeseen medical expenses. Hospital plans and medical aids are two of the fundamental choices that might be made.
👉 Both of them are worth examining, so let’s get started:
What are the features of a hospital plan?
👉 If you are hospitalised, the costs of your medical care can add up quickly. Having a hospital plan can help you pay for those charges. Your plan will contribute a predetermined amount towards the costs of your admission, stay, medical bills, and any other expenses that are incurred.
👉 It is important to remember that not all hospital plans are created equal; although some provide more generous coverage and lower out-of-pocket costs, others have more stringent rules, limitations, and exclusions.
👉 It is essential that you are aware that hospital plans will only reimburse you for costs incurred while you are a patient at an affiliated medical facility. Out-of-hospital charges, such as visits to your primary care physician and acute medication, will be your responsibility to pay for.
👉 Fortunately, even if you are not currently admitted to the hospital, you are required to have prescription coverage for a predetermined list of 25 chronic conditions if you have a medical aid plan, regardless of whether or not you have a hospital plan.
👉 You will need to acquire pre-authorization from your provider before you may be admitted to the hospital unless the situation is an emergency, in which case the hospital will arrange admittance with your physician on your behalf.
READ more about the Best Hospital Plans for Pregnancy / Maternity Coverage in South Africa
What are the features of medical aid?
👉 A medical aid can assist you in paying for both in- and out-of-hospital medical expenses. This is the most significant distinction between the two different kinds of medical coverage. Medical aid programmes will pay a predetermined amount for various out-of-hospital expenses, such as visits to the doctor, the purchase of prescriptions, optometrist services, and dental care. These benefits change depending on the type of plan that you select; nevertheless, as a general rule, the more comprehensive the plan, the more situations that are covered under it.
👉 You can add family members to any form of the medical aid package, so it is important to do an extensive study on the plans that are available. Some of the plans are best suited for single people, while others are better suited for families.
👉 No matter what degree of protection you choose when you join a medical aid plan, you will always be entitled to a base level of medical coverage. This consists of a list of 270 ailments and 25 chronic diseases and provides coverage for emergency medical situations as well as required minimum benefits.
What are the biggest differences between a medical aid and a hospital plan?
👉 Medical aids cover a significantly wider range of expenses than hospital plans do. While a hospital plan will cover treatment and medical costs that emerge while the insured is booked into the hospital, a complete medical aid plan will cover hospital charges as well as other private medical requirements such as consultations with specialists, visits to the primary care physician, and further tests or procedures.
👉 There are two main differences, the first advantage being that hospital plans come at a significantly lower cost than medical schemes. The second difference is that hospital plans require you to cover almost all of your day-to-day out-of-hospital costs yourself (depending on the plan).
👉 The law requires that the medication for 26 chronic conditions must be covered by all medical plans, including hospital plans. Your scheme may insist that you get the medication from a designated provider, however.
For example:
👉 If you have flu and your general practitioner prescribes medicine, 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.
👉 If you have a hospital plan, neither the GP visit nor medicine will be covered.
👉 If you are diagnosed with asthma and need chronic medication, your medical aid will pay for it, since it is legally obliged to cover certain chronic conditions, including asthma. Your medical aid may require proof of your condition from a doctor before they will pay, subject to the payment rules of your plan. There also may still be some shortfalls that you’ll need to cover yourself.
👉 If you have a hospital plan from medical aid, it will be subject to the same legal requirements for the defined list of chronic conditions, including asthma. So you would be covered too, subject to the same rules of your plan.
READ more about Best Medical Aids that covers Chronic Illness
Things to consider when choosing a hospital plan or medical aid.
What are your medical needs?
👉 If you are healthy and unlikely to have high ongoing day-to-day costs, a hospital plan might be enough to cover your needs.
👉 If you are older, or have ongoing medical problems, you should consider a more comprehensive medical aid to avoid being bankrupted by out-of-hospital expenses.
👉 Consider your whole family’s medical history when choosing, especially the occurrence of any chronic conditions that could be diagnosed in you or your children.
What about joining a medical scheme later or when you become ill?
👉 Joining a medical scheme later in life will cost you much more. You will probably have to pay a higher premium as a result of your age and possible pre-existing conditions.
👉 You will also be excluded from any benefits for treatment for a particular condition for up to 12 months, and a general exclusion for three months.
Who should get a hospital plan?
👉 Because a hospital plan is less expensive than an all-inclusive medical aid, it could be an attractive choice for people with lower incomes or better health who are interested in gaining access to private treatment.
👉 Medical aid hospital plans also cover the 25 required minimum benefit for chronic diseases; however, your decision should be impacted by whether you are willing to self-fund additional general out-of-hospital expenses as an alternative to paying the higher monthly premium for a full medical aid plan.
👉 When making this choice, it is essential to check to see if there is a designated service provider (DSP) for the particular plan or scheme that you have in mind. This is one of the most crucial considerations. Frequently, medical plans will have negotiated discounts with specific hospital chains, which will lower your costs but also restrict your choice of facility.
👉 Both hospital plans and medical schemes are subject to regulation and oversight by the Medical Schemes Council, which is vested with jurisdiction under the Medical Schemes Act of 1998.
👉 Even the hospital benefits that come with full medical plans have specific limits, which is another aspect that you should think about before signing up for a plan. Some plans have relatively low hospitalisation limits, which would leave the member and their three dependents without adequate protection in the event that they were all injured in the same accident.
👉 If money is limited and you have the option of purchasing a hospital plan or going without any form of medical coverage at all, the hospital plan is the most financially responsible decision. However, if you are in a position to be able to pay full membership in a medical scheme, doing so does bring some degree of peace of mind, as a significant portion of your regular expenditures will be covered.
👉 But that is by no means all; check to see if you have a Medical Savings Account available to you and determine what expenses must be covered using the money in that account.
👉 The demand in the market for more reasonably priced hospital insurance has been met by a number of different companies. Although the monthly payments for some of these plans are relatively low, the benefits they provide are also relatively modest.
👉 However, having even this level of protection is far preferable to having none at all. Some policies require you to make use of a certain hospital network, which is acceptable so long as there is one conveniently located near your place of residence.
👉 Speak to a broker and analyse the various plans’ contributions in relation to their benefits.
When to get a full medical aid
👉 This choice is determined by the extent to which you are able to pay monthly contributions as well as the total amount spent on non-hospital expenses. If the amount you spend on non-hospital care is greater than the amount it would cost you to pay for a comprehensive medical aid plan over the course of a year, you would be better suited to enrol in the latter.
👉 A great number of plans merely consist of savings account components that cover your spending outside of hospitals. In this case, it is essential to keep in mind that the costs being incurred are being paid for by your own money, and not by the scheme itself.
👉 Your coverage history will be used to determine the length of any waiting periods required for new members joining any sort of medical aid programme. For instance, if you have been enrolled in a medical aid programme for a duration of two years or longer and wish to move without an interruption in coverage, the new programme you enrol in can only impose a general waiting time of three months on you.
👉 A general waiting time of three months and a pre-existing condition waiting period of 12 months may be imposed by the medical aid if you have not previously been covered or if your coverage has been interrupted at various points in the past.
👉 When someone joins medical assistance for the first time beyond the age of 35, the medical aid company has the right to increase their monthly charge by an additional amount known as a loading fee. This is referred to as a late-joiner penalty, and the additional percentage that is added to the monthly contribution is determined by both your age and the number of years that you have gone without health insurance coverage.
👉 Think about your finances, the health of you and your family, your medical history, any problems that run in your family that are inherited, chronic diseases, and any therapeutic needs, and also take into account whether or not you plan to have children soon.
👉 After that, you can compare several medical assistance online to establish which one is most suitable for your circumstances.
You might want to know more about when you join a medical aid late, the penalties imposed
Frequently Asked Questions
Is a hospital plan the same as a medical aid?
No, there are major differences between hospital plans and medical aid. One obvious difference is the fact that a hospital plan only covers procedures and treatments done in hospital while a medical aid can cover other day to day out-of-hospital expenses.
Is a medical aid better than a hospital plan?
Yes, a medical aid is better than a hospital plan. A medical aid scheme charges members a higher monthly premium for a set of standardized benefits that include more treatments and conditions as a hospital plan.
How do you determine if you should choose a medical aid plan or a hospital plan?
Before selecting either a medical aid plan or hospital plan, take into consideration your coverage needs, budget constraints, risk tolerance level and expected healthcare expenses. Medical aid plans provide extensive hospitalization coverage as well as day-to-day expenses making them suitable for those with greater healthcare requirements and greater resources, while hospital plans focus more on inpatient treatments with more cost-effective premiums that cater specifically for in-hospital treatments and provide more cost-effective coverage options for individuals who only require limited in-hospital treatments. Consider access to hospitals/specialists/additional benefits as well as consulting professional to make informed decisions tailored specifically towards your individual circumstances when making these choices.
Should I change to a hospital plan or go without any medical coverage when facing financial constraints?
When money is tight, it is best to choose a hospital plan and still enjoy a certain amount of coverage rather than go without any medical coverage at all.
Is there a difference in chronic medication cover between medical aid plan and hospital plan?
Medical aids are required by law to cover certain chronic conditions. A hospital plan provided by medical aid will be subject to similar legal requirements, for a defined list of chronic diseases.