Healthcare is expensive, but so necessary if you want to be able to afford the finest medical care.
In order to find and join the best plan for your needs and budget, you must have a basic idea of what types plans are on offer.
All medical scheme plans offer hospitalisation and certain chronic treatment benefits. It is with day-to-day or out of hospital cover where you have a choice.
In an attempt to fight the high costs of healthcare - but still have protection for high private care expenses - many members are joining only hospital plans and self-funding day-to-day costs.
There are 2 general forms of medical cover:
Comprehensive Plans are designed for members who have high out of hospital or chronic illness, medical costs.
In addition, for families who want the security of knowing high medical costs associated with children are covered and the elderly, who have higher needs for medical treatments.
They include full cover for hospitals, benefits for a number of out of hospital needs, like doctor's, specialists and medication, along with cover for an extensive number of chronic illness.
1. Traditional plans have defined out of hospital benefits and limits per treatment.
This prevents a situation of having used all the benefits on one condition, with nothing left for other healthcare needs - as can happen with saving plans.
Claims are paid from a a common pool of funds within the medical scheme, a form of cross-subsidisation. No benefits are carried over into a new year. It is a use or lose type cover.
2. New Generation plans offer the same in-hospital benefits as Traditional plans, however they have a savings fund from which all day-to-day costs are paid.
Some plans offer a safety net (additional cover or threshold benefit) should the funds be used up. A portion of your premium is saved into this fund and only you can spend the monies on your medical needs - there is no cross-subsidiatation amongst other members. Any funds remaining at year-end are carried forward to the next year.
3. Network plans (Capitation Plans) require you to use providers who are linked to the medical scheme.
For that, you get a discounted premium because the scheme is able to control the costs of treatments by creating preferred networks of providers. (In an emergency you should be able to use any hospital, but please check with the plan rules)
Medical schemes have network provider plans to give members, who are happy to use a network of providers, excellent benefits for an affordable premium!
There are Network plans, with premiums related to your income.
These are the lowest cost medical scheme plans available. However, they can be restrictive in the benefits they offer, but do offer life-threatening and life-sustaining benefits for extremely good rates!
They are ideal for pensioners, children who become adult dependents on your healthcare plan, students and those who earn low-incomes, but want access to private healthcare.
Hospital plans are designed to meet the need for high cost, elective and emergency private hospitalisation and essential chronic illness treatment.
Most medical aids offer these plans.
These plans offer the best method of controlling medical aid costs, by "insuring " for the greatest medical financial risk we face - private hospitalisation - whilst you self-pay for your day-to-day costs. They are recommended for those with a strict budget or healthy members who have little need for out of hospital cover.
Benefits include all planned and emergency, in hospital costs from admission to discharge. That includes ward and theatre fees (which are normally fully covered), anaesthetist and surgeon, pathology, physio and other providers.
Unless you are admitted immediately after casualty treatment, most plans do not cover casualty costs.
Here is a plan that does pay casualty ward costs, as well as 30 days post hospital costs for certain treatments and allows an upgrade to a higher plan if you suffer a defined life-changing event!
There is a hospital plan that will pay essential dental costs as well, further reducing the risk of self-funding out of hospital costs!
Plans may also offer specific maternity, chronic illness programmes, screening and preventative care benefits.
Some plans offer unlimited cover at network hospitals.
Private provider fees are not regulated and many can charge up to 500% of the medical scheme rates! Some plans pay claims at 200% or 300% of medical aid rates, offering you a lower claim shortfall, but these are more expensive.
Increasingly, plans also have procedure co-payments, which you have to fund.
This separate insurance plan will cover most in-hospital claim shortfalls and scheme co-payments.
By adding a Top Up plan you can improve your medical aid benefits, so-much-so, that you can even consider joining a lower cost/benefit plan - with a lower premium - and still have an excellent, no risk medical aid for virtually the same premium as the higher medical aid!
Hospital Plans with Day-to-Day Savings
Expensive healthcare treatments can occur outside of hospital. If you feel you may need help with these types of expenses, but do not require a comprehensive plan, there are hospital plans that offer day-to-day benefits.
All in-hospital costs are covered as with hospital plans. There are two ways out of hospital claims are paid:
A Medical Savings account may be attached to your plan. Part of your premium funds this account.
At the beginning of a year, the scheme advances you 12-month's worth of these monthly saving amounts - upfront into your fund - interest free. As you claim, so the fund reduces.
Once the savings are used, you pay further costs that year. Any credit balance is carried over to the next year.
Low income earners should be able to access private medical providers, however a standard medical aid plan is way too expensive for their budget. Medical aids have certain plans with income-related premiums.
In fact Discovery Health's keyCare Plan has more members than most total medical aids!
The plans offer hospital, day-to-day and chronic illness cover using a network of providers. They can include day clinics, maternity, HIV, cancer, diabetes and mental health programmes, preventative and screening and even home-based care benefits.
Momentum Health's Ingwe plan covers the use of any hospital, or a network of hospitals for a further premium discount, or state hospitals with the lowest of all premiums.
These plans offer life-threatening (heart attack, car accident etc.) and life-sustaining (cancer, kidney etc.) benefits for a very affordable premium, which you do need to prove!
Full time students also have access to medical aid.
Benefits include unlimited hospitalisation at any hospital (including casualty), mostly unlimited basic day-to-day cover with network providers. Dental and optical benefits are included.
This medical aid is recognised by Home Affairs for study visas that International students require. And we can get you your certificate in a very short time!
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Last update: April 6, 2021<
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Medical Aid Authority Peter Pyburn.
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