What is health insurance? How does it work? What does it cost? Get your answers here!

People in South Africa who want cover for private healthcare are able to buy either health insurance or medical aid products. But what exactly is health insurance? And what is medical aid? What are the differences between health insurance and medical aid? How much does health insurance cost?

Understanding how health insurance works in South Africa, and how it differs from other healthcare cover options, is key to being able to choose cover that suits your health needs and budget.

Here we answer the most common questions people have about health insurance.

What is health insurance?

Health insurance gives you access to basic medical care at private health facilities.

With health insurance, you pay the same amount every month (this is called a premium) to have everyday access to primary healthcare (and not pay more for this care). This includes doctor (GP) or nurse visits, basic dental and eye care, some medicines, and care for some medical emergencies in a private hospital.

By paying extra every month, you can add your family to your policy so they can get the same care.

Health insurers usually have arrangements with groups of doctors, nurses, dentists and other healthcare providers to help members get quality care at lower prices. These are called provider networks.

Health insurance is a product governed by South Africa's insurance laws and regulated by the Financial Sector Conduct Authority (FSCA).

Health insurers usually apply waiting periods when someone joins. This means members may need to wait before claiming for specific conditions or treatments.

Health insurance is perfect if you cannot afford the monthly cost of medical aid cover but want an affordable way to access private healthcare for everyday needs - with a chance to pay a little more for emergency and private hospital cover.

Flexicare is an example of a health insurance product.

Do 'health insurance' and 'medical insurance' mean the same thing?

Yes. Health insurance and medical insurance mean the same thing and are often used interchangeably. They both refer to affordable cover for basic medical care, like GP visits, at private facilities.

What is medical aid?

Medical aid gives cover for care at private healthcare facilities.

When you have medical aid, you pay the same amount every month to be on the plan type that you choose.

Medical aid plans cost more than health insurance products because they cover members across a bigger range of healthcare types.

With medical aid, there are often many plan types to choose from, ranging from plans that are mostly for hospital cover to plans with medical savings accounts, to the most expensive plan types, which offer the most comprehensive coverage.

You can add your family to your policy for a higher monthly premium.

When you see a doctor or get care, the medical aid either pays the doctor directly, or you pay first and then the scheme pays you back.

Medical aid covers your costs for everyday care (the amount of cover you get for things like GP visits, specialist doctor visits, medicine, and more depends on your plan option). Medical aid also covers you for major medical costs, like when you need care in hospital

Medical aids are governed by the Medical Schemes Act and regulated by the Council for Medical Schemes.

Waiting periods may apply for certain conditions when joining a medical scheme.

Medical aid is a great option for people who can afford a higher premium than what they'd pay for health insurance. Medical aid is for people who want cover against unexpected medical events that cause large costs that few people can afford - such as extended hospital stays or long-term care after an accident, injury, or serious illness. Medical aid is also ideal for families, people who need regular medical care or have chronic illnesses, and anyone who wants broad cover for their healthcare needs now and into the future.

Discovery Health Medical Scheme is an example of a medical aid.

What are the key differences between health insurance and medical aid

It is true that both health insurance and medical aid give people access to private healthcare for a set monthly payment. What is different is the kind of private care that members have access to through each product (and so the monthly costs of the products are different too).

Here is a summary of the key differences between health insurance and medical aid:

Feature	Health insurance	Medical aid
Cover for primary private healthcare like doctor visits	Yes	Yes, but level of cover is dependent on your plan option.
Cover for stays at a private hospital	You usually have to pay a slightly higher premium to get hospital cover for accidents and emergencies.	Yes. Most medical aid plans provide comprehensive coverage for hospital stays.
Can dependents, like children, be added to the plan?	Yes, you can add your family members to your policy for a higher monthly premium.	Yes, you can add your family members to your policy for a higher monthly premium.
Regulated by	Insurance industry.	Medical Schemes Act.
Monthly cost	Usually lower than medical aid.	Usually higher than health insurance.
Waiting periods	Yes, waiting periods are applied for specific conditions or treatments.	Yes, waiting periods are applied, especially for pre-existing conditions.
PMBs	Not included.	Must be covered.

Whether you chose health insurance or medical aid depends on the premium you can afford to pay every month and you and your family's healthcare needs.

Is Flexicare a good health insurance option for you?

Yes. Flexicare is a trusted and affordable health insurance product.

When you have Flexicare, you pay a set monthly premium. When you need to see a healthcare provider, like a doctor, Flexicare will pay the doctor directly. You will not need to pay the doctor yourself or pay anything extra.

Flexicare covers a wide range of essential services like nurse and doctor visits, some medicines, basic dentistry and optometry, pregnancy care, HIV care, and more.

Flexicare members can add emergency cover to their plan. For a slightly higher monthly premium, you can get care in a private hospital after an accident or emergency.

Flexicare has a large network of private doctors, pharmacies, dentists, and optometrists across South Africa. Flexicare is simple to understand and easy to use.

What does health insurance cover you for?

Health insurance covers basic healthcare services like visits to the doctor and medicines.

In the case of Flexicare, there are two plan options, each with different types of cover.

What does health insurance cover you for?

Health insurance covers basic healthcare services like visits to the doctor and medicines.

In the case of Flexicare, there are two plan options, each with different types of cover.

For R459 per month, Flexicare Core gives you:

• Unlimited visits to a nurse as needed
• Doctor visits when a nurse says it is needed
• Online doctor visits
• Acute and over-the-counter medicines
• X-rays
• Flu vaccine
• A Health Check
• Care during pregnancy
• Blood tests
• Small medical procedures done at a doctor
• HIV care

For R539 per month, Flexicare Plus gives you:

• Unlimited visits to a doctor as needed
• Unlimited online doctor visits
• Visits to specialist doctors
• Acute, Chronic and over-the-counter medicines
• X-rays
• Flu vaccine
• Optometry
• Dentistry
• A Health Check
• Care during pregnancy
• Blood tests
• Small medical procedures done at a doctor
• HIV care

Can I use health insurance, like Flexicare, at any doctor?

Most health insurers have special arrangements with groups of top-quality private healthcare providers, such as doctors, dentists, optometrists, and pharmacies, who charge set rates for members. These are called network providers. This means when you see these providers you pay less for access to private healthcare than you would have without your Flexicare cover.

Members' care is fully covered when members visit healthcare providers in the network - there is nothing else to pay! Flexicare pays these healthcare providers directly, so there are no extra costs or co-payments for you when you see them.

If you see a healthcare provider outside the network, the cost of their care will not be covered by Flexicare.

Will health insurance cover hospital stays?

Health insurance does not usually include full hospital coverage. However, some health insurance products offer optional emergency cover for an additional monthly cost.

For example, Flexicare members can choose to sign up for Discovery Emergency Cover. This pays for emergency treatment after an accident, injury, or emergency that needs hospital care. Monthly premiums will be a bit higher if Emergency Cover is added. The member must already have a Flexicare Core or Flexicare Plus membership to be able to sign up for additional Discovery Emergency Cover.

There are three Emergency Cover options. Each option gives a different amount of cover:

Emergency Core, from R218 per month

Pays for care in a private hospital after an accident or injury.

Emergency Plus, from R313 per month

Covers everything in Emergency Core. It also pays to be stabilised at a casualty unit during an emergency, and for care in a private hospital after a heart attack or stroke.

Emergency Max, from R439 per month

Covers everything in Emergency Core and Plus. It also pays for private hospital treatment for these nine serious conditions: Acute appendicitis, acute asthma, ectopic pregnancy, acute inflammation of gall bladder, fit or seizure, acute pneumonia (serious lung infection), kidney stones, acute renal failure (kidney failure) and pulmonary embolism (blood clot in the lungs).

Does health insurance cover your dentist visit?

Each health insurance product is different, but many plans include basic dental cover.

The Flexicare Plus option covers procedures such as cleaning, scaling, polishing, extraction and fillings at dentists in the Flexicare network.

Does health insurance cover your eye care?

Many health insurance plans cover basic optometry.

Flexicare Plus pays for eye tests, frames and lenses from optometrists in the Flexicare network.

What medicines are included in health insurance plans?

Most health insurance plans pay for certain medicines.

Flexicare Core pays for acute and over-the-counter medicines. Flexicare Plus pays for acute, chronic and over-the-counter medicines from pharmacies in the Flexicare network.

Health insurance that fits real-life budgets

Health insurance makes private healthcare more accessible and affordable for more people in South Africa. If you have health insurance, you can get private care close to home exactly when you need it, limiting time off work.

Flexicare is affordable health insurance that's easy to use, and covers visits to private doctors, dentists, optometrists, and pharmacies.

With monthly premiums starting from just R459, Flexicare offers real value for real healthcare needs.

Learn more about Flexicare.