A medical aid hospital plan is gradually becoming a popular choice among South Africans as it is significantly cheaper than comprehensive plans It is essentially still a medical aid but without the out-of-hospital cover that pays for day-to-day medical services. A medical aid hospital plan usually has a chronic medicine benefit included with the in-hospital cover. This means that a member on a hospital plan can rest assured of services when hospitalised in addition to medication for their chronic disease. A medical aid hospital plan should not be confused with a hospital cash back plan – the latter is not a medical aid.
Hospitalisation Cover
Private health care in South Africa is expensive but far surpasses the services in state facilities. The most expensive component of private health services is the in-hospital costs. This includes the fees for :
- Hospital stay per bed and depending on the ward.
- Doctors and other health professional fees for consultations and treatment in hospital.
- Surgery including operating theatre costs, consumable, anaesthetic, drugs and prosthetics.
- Diagnostic investigations conducted when hospitalised including blood tests, x-rays, computed tomography (CT) scans and magnetic resonance imaging (MRI) among other procedures.
Medical Aid Exclusions
Medical aids do not cover procedures that are considered non-essential whether you have comprehensive cover or only a medical aid hospital plan. This includes cosmetic surgery, fertility treatments and radical procedures that are not verified to be clinically effective. A few restricted medical aids may cover fertility procedures but only up to a certain point. However, the majority of open and restricted medical aids do not cover these procedures and patients will have to pay for it in cash.
Pre-Existing Conditions
The other exclusions revolve around pre-existing conditions. This means that any disease or condition which was existing prior to joining the medical aid hospital plan will not be covered for a period of one year. Medical aids do this for both comprehensive plans and hospital plans to ensure that new members do not join a scheme, drain resources and leave shortly thereafter. The costs incurred for a pre-existing condition is covered after one year of membership. Pre-existing conditions also includes pregnancy. There is no cover on a hospital plan medical aid for pregnancy and childbirth costs if a woman is already pregnant when joining the scheme.
Costs of a Medical Aid Hospital Plan Only
These costs are overwhelming for most people and not affordable without medical aid cover. A few days in hospital with surgery can easily run into the hundreds of thousands with some procedures. When one looks at the cost of a hospital plan, it just makes more sense than attempting to bear the hospital costs without cover.
For example, a medical aid hospital plan may cost as little as R600 per month or a single member yet will cover the costs of bypass surgery and hospitalization in the event of a heart attack which can be as much as R250,000 incurred within just a 10 day period. These monthly contributions are miniscule in comparison to the benefit.
No medical aid hospital cover
Should you not have a medical aid, you will have to pay cash for your hospital bills. All private hospitals in South Africa insist on a cash deposit upfront before admission if you do not have a medical aid. This can vary from hospital to hospital but may start from a few thousand rands to tens of thousands of rands depending on your ailment for which you require hospitalisation.
Without paying this deposit you will not be allowed admission into the hospital and will instead have to seek medical assistance from a government hospital. Upon being discharged, you will be required to pay the entire hospital in full immediately. Some hospitals may give you a leeway for a few days or weeks to settle the bill but this is rare. For this reason they usually take a credit card upfront and reserve funds ahead of time.
Chronic Medication and Disease Cover
Medical aid hospital plans provide a separate benefit where medication for the treatment and management of chronic diseases are covered by the scheme. This is in spite of not having day-to-day cover. However, not all medical bills with regard to the chronic disease are covered. Only the medication and to some extent the monitoring of the response to treatment and the disease progression are included in this benefit.
The chronic cover benefit on a medical aid, whether on a comprehensive plan or just a hospital plan, is not unlimited. It can be exhausted within a year and then patients are required to pay for their chronic medication in cash. However, medical aids do their utmost to make these chronic medication benefits sustainable for an entire year of cover. It becomes a little difficult to do so when a member has several chronic diseases or more than one member on the hospital plan needs chronic treatment.
Prescribed Minimum Benefits (PMBs)
Medical aids are now required to provide unlimited benefit for the treatment of some 25 chronic diseases and the emergency diagnosis and immediate treatment of 270 medical conditions. This is known as prescribed minimum benefits (PMBs). It ensures that patients have access to medical services when it is immediately needed even if their chronic benefit is exhausted. This is a form of protection for ailments that can prove to be life threatening if immediate and appropriate medical attention