Medical aid schemes are tailored to suit your lifestyle, family size, age, health and many other factors, meaning that there are countless products on the market at any given time.
But what are the main differences between ‘comprehensive’ medical cover and something far simpler like a hospital plan?
From the offset, medical aids can be broadly separated into three main categories: hospital plans, saving plans and comprehensive plans – each increasing in cost.
- A hospital plan, as the name implies, provides cover for serious health problems and stays in the hospital, but leaves day-to-day needs (like medication, doctor visits and things like optometrists and dentists) up to the individual to cover.
- Savings plans provide a little more cover, and attach a savings accounts (where you contribute a percentage of your premium to each month), that pays for day-to-day needs.
- Comprehensive plans have the highest cost, but also cover the widest range of health services and chronic illnesses. These schemes typically cater for people who suffer frequent health issues, especially among the older population.
South Africa’s medical aid companies all offer plans along these three main schemes, with tailored limits and requirements.
BusinessTech looked at the most expensive medical aid cover available in South Africa, as well as the cheapest option from the same company, to show where the key differences lie.
How the most expensive and cheapest options compare
According to the GTC Medical Aid Survey for 2017, Fedhealth’s Ultimax scheme is the most costly medical aid scheme in the country, at R9,215 per month. For a family of four (Two adults and two children), the scheme costs R18,100 a month.
These types of schemes are typically targeted at, or at least cater for older people, who are more prone to chronic illnesses, and thus more likely to need cover for frequent hospital visits and medication.
For the higher monthly fee, members get:
- Price: R9,215 pm
- Family of four: R18,100 pm
- No annual limits to cover
- No restrictions to which hospital they can use
- Unlimited cost cover on the Fedhealth network
- 100% cover off-network, and 300% cover for off-network specialists
- Cover for the legally-required 25 chronic illnesses, as well as 40 others.
On the face of it, the Ultimax scheme is practically unlimited, with restrictions being placed only on things like prostheses and psychiatric services, as well as some specialised medication.
Fedhealth’s cheapest plan, the Maxima Dynamic Hospital Plan, costs ‘only’ R876 per month, if your income is below R8,000. The same family of four, under these conditions, would pay R1,955 per month.
Under a hospital plan, healthcare costs are far more restrictive, often limiting members to networked doctors and hospitals, and providing cover for a more limited number of chronic illnesses.
However these plans typically do not have savings accounts (where a portion of your monthly premium is stored for day-to-day use), leaving members to cover doctor visits and over the counter medication out of pocket. By law, all medical aids must cover the medication for 25 chronic illnesses – even hospital plans.
- Price: R876 pm
- Family of four: R1,955 pm
- No annual limits to cover
- Full cover of negotiated payments at networked hospitals (co-payments apply at off-network hospitals)
- Full cover for on-network specialists – no benefit for off-network specialists (pay out of pocket)
- Many procedures are only covered if they take place in a state facility
- Cover for the legally-required 25 chronic illnesses
While the details, terms and conditions differ across medical aid companies, all top-tier “comprehensive” medical aids have similar offers – and share the same differences with their lower-tier “hospital plan” counterparts.
For a full breakdown of medical aid costs, read BusinessTech’s previous coverage: The cheapest and most expensive medical aids in South Africa in 2017
Medical aids at risk
Medical aid schemes in South Africa are facing an uncertain and rocky future as the South African government plans to move ahead with its National Health Insurance (NHI).
NHI will be compulsory, and every South African will have to pay for it in some way. One of the key proposals to cover fees, is to use tax credits awarded to medical aid holders.
Research conducted by Econex has shown that these changes could leave as many as 2 million South Africans in the lurch, making medical aid unaffordable, and forcing them onto public healthcare.
According to Econex, tax credits are taken into account when considering the affordability of health cover, and by removing this incentive to fun the NHI, it would take private healthcare out of reach of those on the lower-tier (hospital plan) schemes.
“Removing the rebate will likely have the effect of rendering medical scheme membership unaffordable to 22% of current beneficiaries (1.9 million people), with the impact falling largely on poorer medical scheme beneficiaries,” the group said.