You get what you pay for, and hospital plans are no exception to this rule. Lurking in the benefit schedules can be some very definite restrictions that you need to be aware of.

While the law states that all medical scheme members have to be covered in full for prescribed minimum benefits (PMBs) you might be hospitalised for something that is not a PMB.

There are also other things that lurk in the benefit schedules of many hospital plans which could leave you seriously out of pocket. It might be an idea to investigate exactly what you are covered for, and more importantly, what you are not.

Here are some things to look out for:

100% of fund/scheme rate. If that’s what your hospital plan pays, it doesn’t mean your hospital bill/doctors’ bills in hospital are covered 100%. The fund or scheme rate can be significantly lower than the costs of the hospital or the private doctors in the hospital. This is why it might be advisable to pay a bit extra, and get a hospital plan that covers you for 200% of the fund/scheme rate – and also consider getting gap cover.

No overall annual limit. This doesn’t really mean much. All high-cost cases are monitored by schemes in order to protect the interests of other members and the solvency of the fund. Strict medical protocols are in place for certain procedures/treatments, and if your treatment falls outside of these guidelines, it will most probably not be funded. No fund will pay for experimental treatment, for instance, or will pay for an operation if only your doctor thinks it is necessary.

Network hospitals to be used. If you don’t use a network hospital for a planned procedure or you don’t get a hospital admission number, your plan does not have to cover you at all. Some schemes might still pay a certain amount, but can ask for a co-payment of thousands on voluntary non-network admissions.

Co-payment on admission. Some low-cost hospital plans require a co-payment on admission for anything except motor vehicle accidents, emergencies and admission to the maternity ward. If your scheme does this, you need to make sure you have always have that amount available before you go to hospital.

Network Day Clinics to be used for certain procedures. Check this list – there could be some procedures on there that would sometimes possibly warrant a night in hospital.

Subject to scheme formulary (chronic medication). All hospital plans have to pay for medication for 27 PMB Chronic Disease Conditions, but many of them have a rand value attached to the medication for the condition, or a list of specific medications that it will pay for. These are often generics, which is fine, but sometimes not even these are covered in full, especially if you take more than one type of medication for a particular chronic condition. Also check whether you are restricted to using certain pharmacy chains or medical delivery services, and whether they operate in your area.

Payment for prostheses. These can be both internal and external, and some of the cheaper hospital plans will only cover prostheses that are PMBs, or they have a maximum amount in rand that they will pay towards this. A prosthesis is an artificial device that replaces a missing or injured part of the body, such as is used in a knee replacement, or when someone loses a limb. Each scheme has its own rules with regards to these – make sure you know them.

Psychiatric treatment. There is often a lump sum allowed per family for psychiatric hospitalisation– and on cheaper hospital plans this can be as low as R23 750. On some of the other plans psychiatric treatment is limited to 21 days per member. If there is more than one person in a family with psychiatric problems, the limited amount won’t get you far.

Co-payments on certain procedures. That means that you will have to make an up-front payment on certain non-PMB procedures, even if performed in network hospitals. You really do need to check the detailed benefit schedule of your hospital plan option. These are things you need to know.

Oncology cover. Many cancers are not PMBs, and often cancer treatment does not take place after a hospital admission. Many cancer patients are day patients. Hospital plans often have a fixed amount set aside for cancer treatment. If yours is low (such as R50 000) you might need to change to another hospital plan option, unless you are happy to use state facilities. Cancer treatment is expensive and can quickly run into hundreds of thousands. Some of the more expensive hospital plans can have a high amount for oncology, but expect a 20% co-payment after say R300 000. That is a good option to go for.

Take-home medicine. If you have been released from hospital, technically medication you take after returning home is for your own account if you only have hospital cover. Some hospital plans will pay for a fixed number of days of take-home medicine, others may restrict you to a rand amount – and others may pay nothing. You need to know these details. Follow-up visits to the doctor after your release from hospital can also often be for your own account.

MRI and CT scans. These are often done as part of a process to diagnose your condition and they are not covered by most hospital plans, unless specified, or if they make up part of the accepted treatment protocol in-hospital. Even so, some schemes still will only foot the bill for certain MRIs and CT scans and could exclude for instance neck or back scans.

Hospice care. Again, this is often limited to a rand amount, or to a number of days (some are as few as 10). On some plans this number or amount also has to cover rehabilitation and step-down facilities. Sometimes the hospice care and the oncology benefit share a rand limit. If you stay in an unregistered care facility, your scheme will not pay.


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