Types of Medical Aid Plans in South Africa
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Frequently Asked Questions: Types of Meedical Aid Plans in South Africa.
1. What are the different types of Medical aid?
With more than 23 medical aid schemes in South Africa and most of them with more than 10 plans on offer, you are sure to find a medical aid that will meet your healthcare needs and budget. Ranging from traditional plans with set benefits, network plans where you use listed providers, and plans with savings funds for out of hospital costs, each plan having its own benefits and limits, you need to fully understand everything your plan of interest offers.Use us, at no additional charge, to help you choose the best plan for your needs.
2. How will a Medical Aid plan help you?
A medical aid will ensure you have access to instant funds to pay for private medical treatment, a necessity in South Africa. It will guarantee you hospital admission without copayments. Whether you require treatment for unexpected accidents, elective surgery, chronic illnesses, or routine medical check-ups, a Medical Aid plan gives you the financial security that you need for high-quality healthcare resulting in quick treatment and recovery.
3. What type of medical aid plan covers hospitalisation?
Private hospital benefits are the foundation of any medical aid plan. They provide immediate funds for expected and unexpected hospital admissions. Every medical aid plan should have excellent, unlimited private hospital benefits. Comprehensive plans should offer the same hospital benefits, but with the option of financial support for out of hospital expenses. Hospital plans are cheaper than comprehensive medical aids because you self-pay day-to-day expenses. Hospital only benefit plans include chronic illness cover and some offer essential dentistry cover.
4. What are the benefits of Comprehensive Medical Aid plans?
Comprehensive medical aid plans provide both in and out of hospital benefits. They are designed for members with a higher need for day-to-day treatments like GP visits, optical and dental services, consequently, they have higher premiums.
5. How can GAP or top-up insurance plans enhance your medical coverage?
Private providers can charge more than the claims payment by a medical aid. This is a concern with high-cost hospitalisation, as a claim shortfall can be substantial. Medical aids also levy co-payments for several procedures. A GAP or top-up insurance is designed to pay a claim shortfall or procedure car payment. It is also possible that by joining a top-up plan, your base medical aid plan can be one of lower benefits and cheaper premium, because the top-up will pay any shortfall. The lower medical aid premium saving is often enough to pay for the top-up. You will now have healthcare cover with greater benefits than a standard medical aid plan. Top-up insurance only pays for in-hospital treatment.
What are the different types of Medical aid?
Medical aid is like having a backup plan when you need the finest medical care.
Whether it's for accidents or illnesses, a Medical Aid plan will make sure you can afford the best treatment.
To choose and join the best plan for your needs and budget, you must have a basic idea of what plans are on offer and how their benefits will help you meet the risk of high medical costs.
Different types of benefits
Hospitalisation.
This is when you admitted to a hospital for treatment. It'important, because hospitalisation can cost a great deal.
That's why it's important that the plan you choose has unlimited hospital benefits.
Out of hospital.
These benefits pay for going to the doctor, getting medicine, or even getting glasses.
Although they can be a lot lower than hospital costs, if you claim a great deal, they can become expensive.
There are various ways to cover out of hospital expenses and it is here where you can save premiums by choosing the type of plan you want to join.
Many medical aid members are joining an in hospital benefit plan and self-funding day-to-day costs.
This is a way to reduce your cost of healthcare.
Here is an excellent plan that lets you control your savings fund. If you do not use it (but have it there as a safety net) you pay only a hospital plan premium!
And don't forget about Chronic illness benefits . Long-term medical treatment and medication can be very expensive.
Medical schemes offer plans that cover all these important areas.
You pay a monthly premium, and have the financial protection you need.
There are 4 main types of medical aid plans to consider:
1. TraditionalThis type of plan covers all your hospitalisation and day-to-day costs in one plan.
You get set amounts of benefits like 10 GP consultations, 2 dentistry visits, one optometry visit and R 5,000 for medicines.
Once you've used up those benefits for the year, you self-pay for further treatments.
Some traditional plans have a daily limit for claims.
Plans can also offer additional benefits like GP or dentistry, so you do not use your limited set benefits for these treatments.
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.
These plans are suitable for members who have a high need of medical services on a monthly basis. GP, medicine, dental etc. visits.
Advantages: If you use one benefit, it does not affect the others. You know exactly what benefits you have at any time.
Disadvantages: Benefits do not roll over to your next year, so if you do not use them, you lose them. That can be seen as a waste of money!
2. New Generation
Your hospital admissions are paid by the plan, and day-to-day costs are paid from a savings account, really an interest-free loan - paid to you at the beginning of the year. You repay savings through an additional portion added to your premium every month - whether you spend those funds or not.
If you don't use it all, it rolls over to the next year.
Fedhealth medical aid offers innovative and attractive way of using your savings. You can save a great deal of premium with these plans.
Most plans offer a safety net (threshold benefit) should you have spent your savings and still need day-to-day cover.
Once your claims add up to a pre-determined amount, they pay further costs that year, subject to some limits.
Genesis medical aid pays essential dental costs, so you don't use your savings on these claims!
These plans are suitable for healthy members who do not need a great deal of day-to-day treatment, but do want the confidence of knowing that if they do, they have protection.
If you have high dental or optometry needs (where sub-limits of a particular medical aid are insufficient) the ability to use more of your savings on certain costs is an ideal benefit.
Advantages: You have the discretion to spend your savings as you want and any unused amount is carried over to your next year.
Disadvantages: You could spend your total savings on one claim and then have nothing for the rest of the year. Or, one family member could spend the entire savings, leaving the rest of the family without cover.
You need self-discipline to effectively manage these plans.
There are also options that use the best of both Traditional and New Generation plans. They have both set benefits and savings all in one plan.
3. Capitated or Network
These plans work with listed doctors and hospitals. You pay a lower premium, but you have to use their network of providers.
Medshield is an example of scheme who have these plans.
Momentum is another scheme that offers discounted premiums for using network providers.
There are plans that have premiums based on a level of 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!
These plans are ideal for pensioners, children who become adult dependants on your healthcare plan, students and those who earn low-incomes, but want access to private healthcare.
They are good options if you're on a tight budget but still want access to private healthcare.
Comprehensive Medical Aid plans cover both in and out of hospital costs.
They're a bit more expensive, but they offer hospital and day-to-day benefits.
Perfect for people who expect to have a lot of medical expenses or who just want to be fully covered, they typically have no overall limit hospitalisation, excellent set benefit amounts or high savings for day-to-day needs and the highest number of chronic illness medications.
4. Hospital Plans
These plans offer benefits to meet high cost, elective and emergency hospitalisation and essential chronic illness treatment.
They're cheaper than comprehensive plans because they only cover the most important of medical costs - private hospital. Recommended for those with a strict budget or healthy members who have little need for out of hospital benefits,
Benefits include all planned and emergency, in hospital costs from admission to discharge.
That includes ward and theatre fees (which are normally fully paid), anaesthetist and surgeon, pathology, physio and other providers.
Private providers can charge up to 5 times what a medical aid pays, so medical aids offer plans that pay in-hospital costs at 2 or 3 times their medical aid rate of claims. Although they are more expensive, they may still may leave you with a shortfall.
You should investigate Gap/Top Up cover to prevent this from happening.
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!
Here is a hospital plan that will pay essential dental costs as well, so your savings last longer.
Hospital plans may also offer specific maternity, chronic illness programmes, screening and preventative care benefits.
Some plans offer unlimited cover at network hospitals.
Private healthcare providers can charge up to 500% of medical scheme rates.Medical aids add procedure co-payments as well.
These are significant concerns for medical aid members.
Protect yourself against these potential threats, by joining Cura's GAP or top-up insurance plan.
OR Zest GAP or top-up insurance plan.
This separate insurance will cover most in-hospital claim shortfalls and any co-payments. It is a vital safety net, ensuring you have adequate benefits for medical treatments without bearing the full burden of unexpected costs.
Protect yourself from soaring medical expenses by bridging the gap between medical scheme rates and the charges imposed by private providers.
Specialised Dental treatments can be extremely expensive!The costs of braces, root canal, implants and so on, can run into thousands of rand. Most treatments are done out of hospital, so are funded from your savings. That can result in less money available for other medical needs and family limits being used on one member only!
Dental treatment is something we all need and it is vital you consider the Best Dental Insurance Plan OR Most Affordable Dental Planin South Africa.
No Medical Aid or have a Hospital Plan only? This plan will help you meet the high costs of both normal and specialised dentistry!
Why not invest in a hospital plan and create your own day-to-day savings fund.
Open a bank savings account, or use your home as an access bond – pay extra into it and use that for day-to-day expenses?
All in-hospital costs are covered as with hospital plans and there are two ways out of hospital claims are paid:
- by way of defined, limited benefits, funded by the scheme itself or
- by way of a savings fund.
An example of a scheme with hospital and defined day-to-day benefit plans.
Example of a hospital and saving fund plan you can fully control.
More on income-related premium plans.
Low income earners should be able to access private medical providers, however a standard medical aid plan is way too expensive for their budget.
As a result, medical aids have certain plans with income-related premiums, specifically for these member needs.
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 provider sand 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!
bestmedicalaid.co.za can help you identify and join one of the top medical aids in South Africa!
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Last update: January 18, 2025