We offer a variety of Hospital Plans and Medical Aid options. The companies we are affiliated with are Discovery Health and Momentum Health.
Selecting a medical aid is important – each plan has a different benefit level and a different pay out when it comes to how they pay for chronic medication, day to day needs, specialist’s bills and hospital limits. The distinction I like to use is to compare medical aid plans/hospital plans to cars – you get cheaper cars and more expensive cars. The greater the luxury, safety features and benefits the more expensive the car, the same is to be said about Medical Aid and Hospital Plans – the more you pay the greater the benefits.
These benefits normally, only become important to you when you become ill. Most disappointments that people have about the Medical Scheme they are on, is because they never understood the product they bought or they purchased the cheaper option expecting a luxury product.
Types Of Medical/Hospital Plans on Offer:
GP Network Plan Comparison
Network Plans:
are generally designed for younger people entering the medical aid market for the first time or for those clients that have a limited medical aid budget.
The Medical Aid companies generally contract with a group of hospitals and GP’s. By doing this they are able to offer medical cover at more affordable rates.
A member will be able to visit his/her chosen GP without having to pay for the consultation. The Medical Aid agrees to pay a monthly amount to the GP, regardless of how often the member visits that GP. The member has access to basic dentistry for which they don’t pay. If a doctor prescribes medicines that are not covered on this plan, the member will have to pay for these medicines themselves, likewise for specialized dentistry. Chronic medicine is limited. Hospital benefits have limits.
With spiraling medical aid inflation, the Network Plans have become far more popular in the last few years.
Hospital Plan with Savings Comparison
These “hospital plans with savings” provide cover for services in hospitals and pay out according to a tariff. Generally at either 100% of Medical Health Tariff or 200% of Medical Health Tariff when the patient/client is in hospital.
The member has a limited savings account for day-to-day expenses (e.g. GP, medicines, dentist, etc.).
Once the savings account is exhausted, the member needs to pay for their day-to-day expenses from his/her pocket.
In the event of a member not utilizing the entire savings available for the year, the remaining balance will be carried forward to the following year.
Chronic medicines and Chemotherapy are covered from the hospital plan and limits for these benefits are set according to the plan they have chosen. As long as the chronic medicine is listed on the scheme, these medicines are paid from the hospital benefit so that the member does not have to pay for these medicines from their medical savings.
Comprehensive Medical Aid Plans:
Comprehensive Medical Aid plans have unlimited hospital cover. An extensive chronic medicine benefit is paid for by the medical aid and there are comprehensive day-to-day benefits. Initial day to day claims are funded from the member’s medical savings account. Day to day funds are accumulated and once the member has reached a specified threshold amount (this amount varies depending on the plan), there will be a self payment gap (where the member has to pay towards their medical expenses). This happens until a threshold benefit has been reached and the benefit of the threshold cover kicks in. When this happens, the medical aid company funds your day to day medical claims (once again this is based on a set formulary). This benefit ends at the end of the calendar year. There are some plans that do not have a self payment gap which means the threshold benefit kicks in immediately.
These plans have generous amounts of day-to-day cover. GP’s consultations are generally unlimited. Chemotherapy benefits and chronic medicines are greater in these plans than the other medical schemes.
TIP
You are only allowed to upgrade your Medical Plan option at the beginning of each calendar year so it is important to review you medical plan in November and ensure that you request your financial advisor to upgrade your medical scheme in January.
We offer medical aid quotes, comparisons and advice get your free comparative quote here.
You can also appoint SM Wealth Coaching as your healthcare consultant if you have an existing discovery health or momentum health plan. We will then be able to assist with claims and query resolutions at your present medical aid and keep you informed with current trends and plan changes on a yearly basis. Click here to request this.
GAP Cover/Top Up Cover:
In our opinion this is a vital product to be purchased along with your chosen medical aid/hospital plan. Not only is it a huge benefit but it is highly affordable.
Why do you need it?
Hospital Plans on all medical schemes will cover the services provided in a hospital, including the anesthetist and surgeon at the recommended health tariff of the scheme you have chosen.
To qualify for this benefit, you would have to be admitted to a hospital.
TIP
Out patients and trauma units are generally not considered a hospital event if you are not admitted into hospital.
The anesthetist and surgeon charge separately and have the choice of charging anywhere between NRPL (National Reference Price List) which is also knows as 100% of Medical Health Tariff and Private Rates. Private Rates are generally two to three times higher than the NRPL Rate. If your anesthetist or surgeon has charged you above the rate that your plan covers you will have to pay the difference yourself and this can amount to thousands of rands. We strongly recommend GAP cover. GAP COVER also known as TOP UP COVER covers the shortfall in your account (the amount between what the doctor has charged and what your hospital plan will pay) this means you will not have to pay these bills the GAP cover will fund this for you.
For more information on GAP cover: