Medical Aid Hospital Plans in South Africa
What are medical aid hospital plans?
Medical aid hospital plans (often called hospital-only plans or hospital benefits) cover your costs for treatment received in a hospital. These plans typically pay for admissions, theatre fees, specialist consultations related to the hospital stay, diagnostic procedures performed in hospital, and sometimes emergency transfers. They do not usually cover routine day-to-day items like GP visits, chronic medication obtained outside hospital, dental check-ups, or optical care — unless those services are directly tied to a hospital admission.
In South Africa, medical schemes are regulated by the Medical Schemes Act, and schemes must offer a Prescribed Minimum Benefit (PMB) for certain conditions regardless of plan. Hospital plans are popular because they protect against the most expensive events (surgery, childbirth complications, serious injury or illness) while keeping monthly premiums lower than full comprehensive plans.
Types of hospital plans in South Africa
Not every hospital plan is the same. When choosing a hospital plan, you will encounter a few common structures:
- Network/in-hospital plans: These plans limit you to a network of hospitals and specialists. Premiums are typically lower, but you must use a network provider to avoid large co-payments or out-of-pocket costs.
- Hospital plans with sub-limits: Instead of an overall annual limit, certain procedures or services have individual limits — for example, R40,000 for orthopaedic prostheses or R18,000 for oncology medication administered in-hospital.
- Comprehensive hospital plans: These are hospital-focused but include limited day-to-day or chronic benefits (e.g., a small GP consult allowance or a chronic medicine list tied to in-hospital care).
- High-cost event protection: Some plans combine hospital cover with high-cost benefit protection (e.g., oncology or renal dialysis) intended to protect members from catastrophic expenses with minimal outpatient cover.
- Hospital plus gap cover: Gap cover is a separate short-term insurance product that bridges the difference between medical scheme tariffs and the fees charged by doctors/hospitals. Many members take gap cover alongside a hospital plan to protect against specialist shortfalls.
Each type has trade-offs between monthly cost, choice of provider, and potential out-of-pocket risk. Understanding these will help you match a plan to your health and financial needs.
Typical costs and how pricing works
Medical scheme premiums depend on factors like plan design, member age, number of dependants, whether you use a hospital network, and the scheme’s risk pool. Below is a realistic snapshot of monthly premiums and key features for typical South African hospital plans as of recent market norms. These figures are illustrative — actual premiums vary by scheme and region.
| Plan Example | Type | Adult Monthly Premium (per person) | Child Monthly Premium | Hospital Limit / Annual Benefit | Common Co-pay / Shortfalls |
|---|---|---|---|---|---|
| SafeCare Hospital Network | Network-only | R750 | R375 | Unlimited in-network; out-of-network capped | R2,000 – R5,000 co-pay if using out-of-network |
| Core Hospital Saver | Hospital with sub-limits | R1,200 | R600 | R1,200,000 per family; sub-limits on certain procedures | 20% co-pay on certain high-cost prostheses |
| Premier Hospital Cover | Comprehensive hospital | R3,500 | R1,200 | Unlimited private hospital access | Low/no co-pay for emergencies; gap risk remains |
| Essential Hospital Plan | Basic hospital | R650 | R300 | R500,000 per family per year | Co-pays of R3,000 – R10,000 on high-cost procedures |
| Specialist Shield + Gap | Network hospital + gap cover | R1,350 (plus R225 gap premium) | R675 | Unlimited network hospital; gap cover up to R120,000/year | Gap cover eliminates many specialist shortfalls up to cap |
How pricing works:
- Older members typically pay higher premiums on many schemes — age-banding is common for certain plans.
- Family policies add dependants at discounted child rates; expect the adult-to-child premium ratio to be around 2:1 to 3:1 depending on the plan.
- Network plans are cheaper because schemes negotiate rates with hospitals and specialists. Choosing out-of-network providers increases risk.
- Waiting periods (e.g., 3 months for general, 12 months for pre-existing chronic conditions) reduce short-term risk for schemes and can affect acceptance.
What hospital plans typically cover — and what they don’t
Understanding precisely what is covered helps avoid surprises. Hospital plans are designed to pick up the bill when you are admitted or when care is provided in a hospital setting. Below is a clear breakdown of typical inclusions and common exclusions. Use this as a checklist when comparing options.
| Covered (typical) | Notes / Examples | Often Not Covered or Limited | Notes / Examples |
|---|---|---|---|
| In-hospital admissions | Room and board, theatre fees, anaesthetist, surgeon fees | GP visits outside hospital | Routine consultations and scripts usually not covered |
| Emergency admission and trauma | Ambulance transfer, emergency theatre costs (network dependent) | Out-of-hospital chronic medicine | Chronic meds usually on a separate chronic benefit or CDVU list |
| Specialist consultation linked to admission | Specialist fees while admitted — sometimes limited by tariff | Dental and optical (routine care) | Only hospitalised dental surgery often covered |
| Radiology and pathology performed during stay | X-rays, CT, MRI done in hospital context | Cosmetic surgery | Generally excluded unless medically necessary (e.g., reconstructive after injury) |
| Prescribed Minimum Benefits (PMBs) | Chronic conditions and emergency treatment defined by law | Pre-existing condition waiting periods | Often 12 months for certain conditions and 3 months for general cover |
| Organ transplants (select plans) | Often subject to case management and approval | Alternative therapies | Some schemes exclude homeopathy, herbal medicine etc. |
Important details to watch for:
- Co-payments: Even with hospital cover, many plans require member co-pays for certain procedures (e.g., R3,500 co-pay for advanced imaging, or a flat co-pay for robotic surgery).
- Tariff shortfalls: Schemes pay according to their own rate (e.g., scheme tariff). If a specialist charges above the tariff, you may be billed the difference unless you have gap cover.
- Network vs non-network: Some plans cover “unlimited” hospital costs only when you use a contracted private hospital; using non-contracted providers can provoke large bills.
How to choose the right hospital plan
Choosing a plan isn’t just about the lowest premium. Think about risk tolerance, family composition, health history, and financial ability to pay unexpected charges. Here’s a practical checklist and a decision framework you can follow.
Checklist before comparing plans
- How many dependants will be covered? (Spouse, children, extended family?)
- Do you need private hospital access, or is a network hospital acceptable?
- Do you have chronic conditions that require medication outside a hospital setting?
- What is your emergency/accident risk (commuting, sports, hazardous job)?
- Can you afford potential co-pays or tariff shortfalls if you choose a lower-cost plan?
- Are you comfortable with waiting periods for pre-existing conditions?
Decision framework
Use this simple framework to match needs to plans:
- Low budget, high-risk aversion: Choose a network hospital plan with good emergency coverage and low co-pays. Expect limited choice of hospitals but fewer surprise bills. Estimated monthly cost: R650–R1,200 for a single adult.
- Balanced family plan: Pick a hospital plan with reasonable annual limits (R1 million +) and limited sub-limits for critical procedures. Consider adding gap cover if you prefer private specialists. Estimated monthly cost: R1,200–R2,500 for couple + children.
- Maximum choice and peace of mind: Choose an extensive hospital plan with unlimited private hospital access and minimal co-pays. Expect R3,000+ per adult per month and potential cost-sharing through higher employer contributions or personal budget.
Practical tips when comparing:
- Request a detailed benefits schedule: look for hospital limits, sub-limits, co-pays, network lists, and case management protocols.
- Check the scheme’s waiting periods, exclusions, and chronic disease list if relevant to you.
- Ask for examples: schemes should show case studies (e.g., cost of appendectomy, caesarean section, hip replacement) to illustrate likely member costs.
- Compare total cost of ownership: premium + expected out-of-pocket costs for an average family scenario.
How to save money — gap cover, tax credits and practical tips
Medical expenses can be expensive, but there are practical ways to reduce overall costs while maintaining protection.
Gap cover
Gap cover is an optional product that pays the difference between what a medical scheme pays for a procedure and what a medical practitioner charges. Gap cover can be particularly valuable for planned surgeries or specialist consultations where tariff shortfalls are likely.
- Typical gap cover premiums: R100–R400 per month depending on age and cover level.
- Gap cover limits: Many products cap per-procedure payouts or have annual caps (e.g., R120,000 per year).
- Fit with hospital plan: Gap cover is most useful with plans that limit specialist tariffs or with network plans where specialists charge above scheme tariffs.
Tax rebate (Medical Scheme Fees Tax Credit)
South African taxpayers who pay medical scheme contributions qualify for a monthly tax credit known as the Medical Scheme Fees Tax Credit (MTC). The credit amount changes annually and depends on the number of dependants covered by the medical scheme.
Example (illustrative): If the monthly tax credit is R350 for the first two beneficiaries and R220 for each additional dependant, a family of four could reduce annual tax by roughly (R350 + R350 + R220 + R220) x 12 ≈ R12,960. These figures are illustrative — always check current SARS MTC rates when doing exact calculations.
Preventative steps and case management
- Use network hospitals and providers where possible to lock into negotiated tariffs.
- Enroll in wellness and preventative programs offered by schemes; these can help avoid expensive hospital stays later.
- Consider managed-care options: case managers can often negotiate better treatment plans, approve cost-effective alternatives and avoid unnecessary admissions.
Other money-saving tips
- Compare total out-of-pocket exposure, not only premiums. A cheap premium might mean hefty co-pays.
- Time elective surgery when you have served waiting periods to avoid exclusion.
- Shop gap cover: look for a product that complements your scheme rather than duplicating benefits.
- Keep medical records and request pre-authorisation for planned procedures — this reduces risk of claim rejections.
How to join, switch, or cancel a medical scheme
Joining or switching schemes is straightforward but requires consideration of waiting periods, medical underwriting (if applicable), and employer rules if you move between employer-sponsored options.
Joining a medical scheme
When you join:
- Complete an application and provide necessary details about dependants.
- Some schemes impose general waiting periods (usually 3 months) and specific waiting periods for pre-existing conditions (commonly 12 months, sometimes 24 for late joiners).
- If joining via an employer, there may be a defined contribution or subsidy; review the employer policy to know your net cost.
Switching schemes
Consider these points before switching:
- Look at the waiting periods you will face in the new scheme — continuous cover provisions may apply, but these differ between schemes.
- Switching to a plan with better benefits may mean higher premiums; compare the full annual cost (premiums + anticipated co-pays).
- Check for late joiner penalties: people who have never been on medical aid and join after age 35 sometimes incur additional fees or penalties on some schemes.
- Notify your existing scheme in writing if you wish to cancel and ensure you coordinate the start date of the new scheme to avoid gaps in coverage.
Cancelling cover
To cancel, contact your scheme and follow their cancellation process. If you cancel without joining another scheme, you will lose access to benefits and may face stricter rules if you later re-apply. Think carefully before dropping cover, especially if you have ongoing health needs.
Frequently asked questions (FAQs)
Below are answers to common queries people have about hospital plans.
Q: Is a hospital plan enough if I have chronic medication?
A: Not usually. Hospital plans generally do not cover chronic medication obtained outside of hospital. If you have chronic conditions, check whether the plan includes a chronic benefit or whether you’ll need a complementary day-to-day or chronic plan. Many members combine a hospital plan with a separate savings account, day-to-day plan, or take prescriptions through a Chronic Disease List where applicable.
Q: How do PMBs affect hospital cover?
A: Prescribed Minimum Benefits (PMBs) mean schemes must cover specific conditions and emergencies regardless of the plan, subject to certain rules and case management. However, PMB coverage may still require you to use certain providers or follow a scheme’s protocols. PMBs do not replace a comprehensive plan but provide critical baseline protection.
Q: Can I be refused hospital cover because of pre-existing conditions?
A: Medical schemes cannot refuse membership on grounds of health status; membership acceptance is not selective. But they can impose waiting periods for pre-existing conditions and limit benefits for a period. Always check waiting period terms when joining.
Q: What happens if I use an out-of-network hospital?
A: If your plan limits hospital access to a contracted network, using an out-of-network hospital could mean co-payments, partial cover, or full member liability for amounts beyond scheme tariffs. If you anticipate using specific hospitals, verify their status with the scheme before admission.
Q: Should I always add gap cover?
A: Gap cover is advisable if your plan has tariff shortfall exposure or you routinely see private specialists who charge above scheme tariffs. If your hospital plan pays market-related tariffs and your chosen specialists charge in line with those tariffs, gap cover may be unnecessary. Compare the expected shortfall risk against the gap cover premium.
Final checklist before signing up
Use this short checklist to confirm you have all the information needed:
- Have you requested a full list of benefits, co-pays, sub-limits and exclusions?
- Are the network hospitals and specialists acceptable to you?
- Have you estimated typical out-of-pocket costs for routine scenarios (childbirth, appendectomy, hip replacement)?
- Have you checked waiting periods and any late-joiner penalties?
- Have you considered adding gap cover or a day-to-day top-up if necessary?
- Do you know how the tax credit or employer contribution will affect your net cost?
Choosing the right medical aid hospital plan in South Africa is about balancing cost, choice, and risk. If you prioritise low premiums and can accept a network, a hospital network plan may be ideal. If you value unrestricted private hospital access and lower out-of-pocket risk, a comprehensive hospital plan is worth the higher premium. Always compare plans using realistic scenarios, request case studies from schemes, and consider gap cover for protection against tariff shortfalls. And finally, consult with a registered broker or the scheme’s client services for clarification on any unclear terms before you commit.
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