Hospital plans explained: what a hospital plan covers and does not cover

Plans differ, but a hospital plan normally pays for care that happens in hospital:

• the hospital ward, theatre and nursing costs
• surgery, anaesthetists and in-hospital specialists, at the plan's rate
• emergencies, including the emergency room
• conditions on the PMB list, including chronic conditions on the Chronic Disease List
• maternity in hospital, on many plans

Discovery describes its Core series as unlimited private hospital cover plus essential chronic medicine cover, with no day-to-day cover. Bestmed's Beat1 pays for in-hospital care at private hospitals and leaves day-to-day costs for your own account. Bonitas says the hospital cover on BonEssential is unlimited, with its network applying.

Most plans expect you to get authorisation before a planned admission.

A hospital plan generally does not pay for out-of-hospital costs:

• routine GP and specialist visits
• acute medicine such as antibiotics
• dentistry and optometry
• out-of-hospital scans and tests, unless linked to a covered admission

That is why it costs less. But the line between plan types is blurring. Medihelp's MedVital lists limited day-to-day benefits. Bonitas' BonCore, a 2026 network hospital plan, includes day-to-day funding for GP consultations. Fedhealth's flexiFED Savvy is a hospital plan with a day-to-day back-up plan. Read the benefit schedule for your plan, not just its label.

A common myth is that a hospital plan has no chronic cover. The Council for Medical Schemes says PMBs cover 271 medical conditions and 26 chronic conditions, plus any emergency medical condition. They must be covered on every option, including a hospital plan.

The Regulations say each option must pay PMB diagnosis, treatment and care in full, without co-payments or deductibles. The catch is the rules. The scheme may require its designated service provider, a formulary and authorisation. Step outside them voluntarily and a co-payment can apply. See designated service providers.

Two limits to know:

• Chronic conditions outside the PMB list are usually not covered on a hospital plan. Some options let you choose a cheaper state chronic network. Momentum's Custom plan, for example, is priced from R2 585 (Associated hospital, State chronic) to R4 472 (Any hospital, Any chronic).
• The PMB wording for pregnancy is "antenatal and obstetric care necessitating hospitalisation, including delivery". Routine antenatal visits and scans are not on that list.

See prescribed minimum benefits.

Many hospital plans are network plans. You use the scheme's listed hospitals and pay a penalty if you choose one outside the list. Bestmed's Beat1 Network charges a R15 025 co-payment for voluntary use of a non-network hospital, and Bonitas' Hospital Standard applies a 30% co-payment. Emergencies are treated differently: the CMS says you may go to the nearest facility in an emergency even if it is not a designated provider, and the scheme must cover the cost.

Check your plan for co-payments on scopes, joint replacements and similar procedures too. See network vs traditional plans.

These are a sample of 2026 main member contributions as published by the schemes. The full list, with dependants and effective dates, is on the hospital plan prices page.

The cheapest plan is not always the best. Compare the network, the co-payments and the hospital rate, and see how to compare medical aid plans.

• It is not hospital insurance. Insurance products pay set amounts and are not medical schemes. A scheme's hospital plan must cover PMBs. See medical aid vs health insurance.
• It is not full protection against specialist bills. The plan pays at its own rate, and specialists may charge more. That shortfall is what gap cover is for.
• It is not exempt from waiting periods. A scheme may apply up to three months' general and 12 months' condition-specific waiting periods to new members without recent cover.

A hospital plan suits people who:

• are generally healthy and rarely see a GP
• want protection against large, unexpected hospital costs
• can pay small day-to-day costs themselves
• are prepared to add gap cover for specialist shortfalls

It suits less well if you have regular GP, dental or non-PMB chronic needs, or a young family with frequent visits. A savings or comprehensive plan may work out better. See hospital plan vs comprehensive.