Medical aid vs. hospital plan

With costs and expenses rising every day, it’s tempting to want to forgo a big-ticket item like medical aid. It’s easy to think, “I’m relatively healthy, so I don’t need medical aid.” 

For some lucky people, they actually never need to use this option, but life and health conditions can be unpredictable. 

Let’s delve into an understanding of a medical aid versus a hospital plan and figure out which option might be better for you. 

Medical aid 

In South Africa, we have private and public (government) hospitals and clinics. It is unfortunate that there is often a marked difference in the quality and level of services between the two, and people who can afford it tend to choose private healthcare. 

Depending on your choice, your medical aid plan will provide in-hospital and out-of-hospital care. Let’s say your medical aid does not include in-hospital care – this means that if you go to the hospital for a surgery or procedure, you will have to pay the full costs. 

The upside of a medical aid is that they are all legally required to cover a list of PMBs (prescribed minimum benefits). These are 270 medical and 25 chronic conditions that every scheme must cover, from diagnosis to treatment and care. It’s the same whether you’re in a government or private hospital. 

Medical aids also include an MSA (medical savings account). Your MSA is what you get from your monthly medical aid payment to use for day-to-day costs and once-off prescriptions. For example, if you pay R5000 a month for medical aid, you get “back” a percentage each month to pay for daily costs. 

You will need to check the fine print about co-payments. These are conditions where you fill in the gap for the expenses your medical aid does not cover. Example: if your medical aid pays R1000 for dentist visits for the year and your extraction costs R2000, you need to pay the balance.

Hospital plan 

With a hospital plan you are covered for treatments, surgeries and procedures that take place at a hospital. The hospital plan does not pay for doctors’ visits, prescriptions from a pharmacy or any other medical needs outside of a hospital. This includes medication. Also, it’s important to know that you must get pre-authorisation from your medical aid before any surgery or procedure and this can sometimes be declined. 

Which is right for you? This answer comes down to your budget and your needs. If you have a family history of health problems, suffer from a chronic condition or have young children, it’s worth investing in a comprehensive medical aid that can see to all your family’s health concerns. 

Good to know 

• A medical aid network is the specific hospitals, doctors, specialists and pharmacies chosen by your plan. Your medical aid will negotiate precise rates with them and will advise that you use these doctors and specialists only. 
• Some medical aids enforce a limit on cancer treatment. This means that if your risk for cancer is high, you may want to shop around for the best option that has unlimited cancer cover or a “gap” cover. 

• Try not to deplete your savings early in the year. Don’t waste it on needless doctors’ visits – first check with your Medirite pharmacist. You may just need an off-the-shelf product. If the problem persists, go to the doctor. 

Disclaimer

This article is for informational purposes only. Always check with your doctor or medical practitioner about any health concerns, before embarking on any fitness or nutrition programme, and usage of any medication.