The Difference Between Medical Aid and a Hospital Plan

In the grand scheme of life, you don't have to worry about trying to decipher the difference between a medical aid and a hospital plan. We know it can feel like you are trying to understand why the chicken crossed the road - we all think we know, but do we really? That's where hippo.co.za comes in to save the day. Let's start with the basics.

☔What is a hospital plan?

A hospital plan is a type of plan offered by medical schemes that only covers in-hospital costs. It's like your trusty umbrella on a rainy day. It's there to cover you when things get stormy, specifically when you find yourself admitted to a hospital. It helps you pay for those unexpected medical costs that arise from hospitalisation, covering your admission, stay, in-hospital doctors' bills, blood tests, and other costs incurred while you are admitted to hospital.

Remember, not all umbrellas are created equal. Some hospital plans offer more comprehensive coverage with fewer co-payments, while others might have stricter rules, exclusions, and benefit limits. You can compare hospital plans on our site today to find the best one for your needs.

🕴️What is a medical aid?

Now, a medical aid usually refers to plans offered by medical schemes that cover more than just hospital costs. It's designed to cover you both in and out of the hospital. This means it helps you pay for medical costs like doctors' visits, medication, optometry, and dentistry, in addition to hospital expenses. The level of medical cover you get depends on the type of plan you choose—the more comprehensive the plan, the more you're covered for. And the more cover you get, the more your monthly premiums generally cost.

Want help with your choice of provider for your medical aid? Get free medical aid quotes and an instant side-by-side comparison on our site.

🚑 What's the difference between medical aid & hospital plans?

So, what's the difference? Well, a hospital plan is like a safety net, catching you when you fall (or in this case, when you're admitted to a hospital). On the other hand, a medical aid is like a safety net plus a team of paramedics on standby, covering a wide range of medical needs, including those that occur outside of hospital walls.

In other words, hospital plans are medical aids that only cover you in hospital, but they are also usually cheaper. Whereas more comprehensive medical aid options may cost more, in general, but they also cover medical needs outside of hospital. None of them give you truly unlimited cover, but medical aids cover your medical day-to-day expenses to the extent detailed in your policy.

It's important to remember that both are medical aid products and these by law, must provide cover for a defined list of 27 chronic conditions and 271 medical conditions.

For example, imagine your husband has come down with a case of man flu. You send him off to the general practitioner who prescribes a cough syrup. With a medical aid, many plans will cover the GP visit and the medication, depending on the terms and conditions of your particular plan, as well as your available day-to-day benefits. However, a hospital plan wouldn't cover this scenario unless your husband was visited by the GP during a hospital admission.

Detailed comparison of hospital cover vs. medical aid cover

Both medical aids and hospital plans cover healthcare services. The difference is the context. Sometimes, you're only covered for services inside a hospital. Sometimes, you're only covered at your selected healthcare provider or at network hospitals. Let's compare more details to better understand the differences.

• Private Healthcare Cover

  With a hospital plan or a medical aid, you get access to private hospitals. However, it's important to note that not all plans cover all private hospitals. Some plans have a network of private hospitals that you're covered at, and if you choose to go to a hospital outside of this network for an elective procedure, you will have to pay a portion of the costs yourself.
  
  Network plans are more affordable than those that allow you to access any hospital of your choice for planned procedures. The difference really depends on what's on offer from the medical aid company and policy you choose.
  
  

• Emergency Medical Care

  We all hope they never happen, but it's essential to be prepared just in case. All types of medical aid products offer coverage for medical emergencies. However, the extent of the coverage can vary. Some plans might cover the full cost of an ambulance, while others might only cover a portion.
  
  Check your medical aid card for emergency contact information. Some plans might also have specific rules about what constitutes a medical emergency, so it's important to read the fine print.
  
  

• International Emergencies

  If you're a frequent traveller, this is something you might want to consider. Some medical aids offer coverage for international emergencies, meaning they'll cover your medical costs if you have a medical emergency while abroad. However, this cover might not be available or could be limited on a medical aid or hospital plan.
  
  

• In-Hospital Procedures

  These are procedures that are done in a hospital, such as surgeries or certain diagnostic tests. Both hospital plans and medical aids cover hospital procedures, but the extent of the coverage is different from policy to policy.
  
  

• Hospital Stays

  The costs associated with staying in a hospital, such as accommodation, meals, and nursing care are generally covered by both hospital plans and medical aids. The extent of the coverage is different for different plans.
  
  

• In-Hospital Benefits

  These are the benefits that cover your hospitalisation costs, including specialist consultations, procedures, and medication during your hospital stay. Both hospital plans and general medical aid plans offer hospital benefits, but the extent of the coverage and co-pay free access can vary greatly depending on the specifics of your plan. Gap cover helps pay for the shortfall between with the specialists in hospital charge and what the medical aid pays. You don't want to be caught without it.
  
  

• Chronic Conditions

  These are long-term health conditions that require ongoing treatment and chronic medicine, such as diabetes, epilepsy, or asthma. By law, all medical aid products must cover the treatment for a list of 27 chronic conditions, known as Prescribed Minimum Benefits (PMBs). Chronic conditions that aren't on the PMB list can sometimes be covered by medical aid companies if they have extended benefits, but it is important to check your chronic cover with them, since medical scheme cover can vary greatly from option to option.
  
  

• Day to Day Benefits

  These are the benefits that cover your day-to-day medical expenses, such as GP visits, medication, and minor procedures that don't require hospitalisation. Day-to-day benefits are typically included in general medical aid plans, but not in hospital plans. So, if you're someone who frequently visits the doctor or needs regular medication, a medical aid plan with day to day benefits might be the better choice for you.
  
  There are different types of general medical aid plans – some have a savings account to cover day to day expenses whilst others have defined annual limits for different expenses. Comprehensive medical aid plans offer either rich annual limits on day to day expenses or an above threshold benefit which acts as further support once your savings account runs out. These plans are typically quite expensive.
  
  

• Additional Benefits

  These are benefits that are sometimes not covered by medical aids or hospital plans, such as international travel cover, oral contraceptives or alternative therapies. It's important to check either your hospital or general cover plan for these benefits if you need them.
  
  

• Wellness Programmes

  A wellness programme is often offered by some medical aid schemes to encourage and reward healthy behaviour (think Discovery Vitality). They offer discounts on gym memberships, healthy food purchases, and other wellness-related products and services. Some even offer rewards for reaching certain health goals. Wellness programmes are usually available on all types of medical aid products by the schemes who offer them.

What about gap cover - do I need it?

But wait, there's more! Have you ever heard of gap cover? It's like the superhero sidekick to your medical aid. Gap cover provides coverage for a number of events, predominantly the difference between what the specialist charges and what the medical aid covers.

It can also cover co-payments, non-designated service provider penalties, and sub-limit shortfalls. You can only get gap cover in South Africa if you are on a registered medical aid. If you have health insurance and not a medical aid product, you can't get gap cover.

If you have medical aid, and you're worried about extra in-hospital costs that may go above the scheme rate you're covered for, you could do with gap cover. It is relatively affordable, and it can take away the surprise costs that exceed what your medical aid plan covers.

Should I choose a full medical aid or hospital plan?

Now, you might be wondering when it's best to opt for an affordable hospital plan or a full medical aid. Well, a hospital plan is generally more affordable than a general cover or comprehensive medical aid, making it a good option for individuals who are in good health or have a lower income but still want private hospital cover.

Hospital plans also cover the prescribed minimum benefit chronic conditions, so your decision should be influenced by whether you are willing to self-fund other general out-of-hospital expenses instead of paying the higher monthly premium for a comprehensive medical aid. In other words, the question is can you afford not to have medical aid?

A full medical aid might be the better choice if your out-of-hospital spend is higher than the cost of paying for a full medical aid over a 12-month period. Many medical aid options simply have savings account components that cover your out-of-hospital expenses. It's important to remember that this is your money and not the scheme paying for these costs

How to choose between a general medical aid and a hospital plan?

Choosing between a hospital plan and a general medical aid can feel like deciding between a braai and a bunny chow - both are uniquely South African, both have their merits, but your choice will depend on your specific tastes, needs and affordability.

Q: I'm young, healthy, and on a budget. What should I consider?

A: South Africans that buy medical aid tend to over-insure themselves because they don't want the risk of not being covered or having access to private healthcare facilities. The most important initial decision is to make sure that your hospitalisation and major medical expense cover suits your needs. Check the exclusions, co-payments, network limitations and any sub-limits on major treatment e.g. Oncology. Once you're happy with the hospitalisation benefits, check the cost of a product that also covers day to day expenses. If your day to day cover runs out early in the year, It's not always financially sensible to upgrade your plan as the cost of upgrading is more expensive than the additional benefits you get.

Q: I have a family and want comprehensive coverage. What's my best option?

A: If you're looking for the full spread - the boerewors, the steak, the chicken, and the salads - a comprehensive medical aid plan might be the way to go. It covers a wider range of medical needs, both in and out of hospital, and can offer peace of mind for families as well as benefits that go beyond the basics. Be cautious, though, not to over-insure, especially of you are all generally healthy.

Q: I travel a lot. What should I keep in mind?

A: If you're a frequent flyer, consider a medical aid that offers coverage for international emergencies. Some medical aids offer it and others don't. It's worth considering if it's relevant to you but your medical aid choice should be primarily dependant on your health needs rather than on whether it offers international travel cover or not.

Q: I have a chronic condition. What's important for me to consider?

A: Both hospital plans and medical aids cover the treatment for a list of 27 chronic conditions. What's important to check is if your chronic condition is on this list. If not, you can check if there is a medical aid plan that includes cover for the specific chronic condition you have and whether the cost of the product is less than the cost of the medication you need on an ongoing basis.

The Bottom Line? Making the Right Choice for You.

At the end of the day, choosing between a hospital plan and a medical aid is a personal decision. It depends on your individual circumstances, needs, and preferences.
If you're still not sure, you can compare medical aid prices and offers at hippo.co.za today. If you're on a medical aid or hospital plan, remember that schemes will be announcing price and benefit changes soon for 2024. Make sure to visit Hippo.co.za for product updates.

Prices quoted are correct at the time of publishing this article. The information in this article is provided for informational purposes only and should not be construed as financial, legal, or medical advice.