Medical scheme options with hospital and provider restrictions can offer lower contributions. Those restrictions also affect where members receive treatment and how much they may pay themselves.
Hospital networks
A hospital network is a group of hospitals associated with a particular benefit option. Networks can change between benefit years and sometimes during the year.
Voluntary use of a non-network hospital for a planned admission may trigger a fixed co-payment, a percentage of the hospital bill, or an exclusion under the option’s rules, subject to applicable prescribed minimum benefit protections. Percentage co-payments can become substantial when treatment costs increase unexpectedly.
A network hospital does not necessarily mean every doctor practising there has a payment agreement with the scheme. Emergency-unit practitioners may also bill separately. An emergency-room visit does not automatically qualify as a prescribed minimum benefit (PMB) emergency.
Designated Service Providers
Designated Service Providers, or DSPs, are healthcare providers appointed by a scheme for the diagnosis, treatment or care of PMB conditions. Schemes also use provider networks for other benefits. Arrangements may include doctors, hospitals, pharmacies and laboratories.
Provider arrangements can differ between benefit options within the same scheme. Network participation can also change, and published directories may not immediately reflect those changes.
A shortfall depends on both the provider’s charge and the scheme’s reimbursement rate. As an illustration, if a doctor charges R1,500 and a benefit pays 70% of a R500 scheme tariff, the payment is R350, leaving a R1,150 shortfall. This is an arithmetic example, not a statement of what a particular scheme must pay for a PMB.
Several practitioners may submit separate accounts for one admission. Gap-cover benefits depend on the policy and do not necessarily cover every non-network or non-DSP shortfall.
PMBs and unavoidable use of other providers
Ordinary network restrictions must be read alongside PMB protections. The Council for Medical Schemes explains that different rules apply where a member cannot reasonably use a DSP, including qualifying emergencies, unavailable services, unreasonable delays or a DSP outside reasonable proximity. These circumstances are distinct from voluntarily choosing another provider.
Nominated GPs
Some options require each beneficiary to nominate a network GP. Specialist consultations may require a referral, while visits to other GPs may have additional limits. The details depend on the benefit option.
The financial effect of a benefit option extends beyond its monthly contribution. Hospital access, provider agreements, referral requirements and co-payment rules all influence potential expenses.
Related GFS resources
- Prescribed Minimum Benefits Made Clear — free guide
- Medical Schemes in South Africa — A Practical Guide
- Choosing Your Medical Scheme Option for 2027? Start Here
Adapted and condensed from material by Claims Hound. PMB context: Council for Medical Schemes.
General education only, not personalised financial or medical advice. Benefits depend on applicable scheme rules and legal protections. This overview does not confirm any specific scheme’s 2027 benefits.
Featured photograph: Docusign on Unsplash. Illustrative image.