A hospital plan covers in-hospital treatment and the Prescribed Minimum Benefits every registered scheme must fund, but little or nothing for day-to-day GP, dentist and optometry visits. This hub explains how the option works, where the gaps sit, and which guide to read next.
Every registered medical scheme option — including the cheapest hospital plan — must fund the Prescribed Minimum Benefits (PMBs): 270 diagnosis and treatment pairs, all medical emergencies, and 27 chronic conditions on the Chronic Disease List. That statutory floor is what makes a hospital plan a genuine safety net rather than an insurance product.
Above that floor, cover differs by option. Most hospital plans pay in-hospital accounts at a defined rate (scheme tariff or a multiple of it), fund approved procedures after pre-authorisation, and exclude routine out-of-hospital care. Some add limited outpatient benefits such as casualty visits, MRI scans or maternity antenatal consultations.
Three gaps account for most complaints. First, specialists who charge above the scheme's tariff leave a shortfall you settle yourself — the reason gap cover exists as a separate short-term insurance product. Second, network plans require you to use a listed hospital group; using a non-network facility for a planned admission usually triggers a co-payment. Third, defined procedures such as scopes, joint replacements and MRI scans often carry a fixed co-payment even inside the network.
Read the option's rules on pre-authorisation, tariff rate and co-payments before you compare monthly contributions. Two plans with the same price can differ substantially on all three.
Hospital plans suit healthy singles, young couples and anyone who can budget for routine care in cash but cannot absorb a private hospital admission. Households with young children, chronic medication needs or frequent specialist visits usually get better value from a plan with a medical savings account or a threshold benefit.
Generally no. A hospital plan covers in-hospital treatment plus the Prescribed Minimum Benefits. Routine GP, dentist and optometry visits are paid from your own pocket unless the option includes a specific outpatient benefit.
Medication for the 27 conditions on the Chronic Disease List must be funded by every registered option, usually through a designated provider and a formulary. Chronic medication outside that list is typically not covered on a hospital plan.
Gap cover is a separate short-term insurance product that pays the difference when specialists charge more than your scheme's tariff. It is optional, but it is the most common way members close in-hospital shortfalls.