Health insurance is a type of insurance that covers medical costs of an insured person.
Insurers use the term “provider” to describe a clinic, hospital, doctor, laboratory, healthcare practitioner, or pharmacy that provides treatment for an individual’s condition.
The “insured” is the owner of the health insurance policy or the person with the health insurance coverage.
How it works
Depending on the type of health insurance coverage a person has,
The insured pays costs out of pocket and receives reimbursement, or the insurer makes payments directly to the healthcare provider.
Types of Health Insurance
There are two types of health insurance
Private health insurance, and
Public health.
There are also more specific types, which are often regarded as plans.
Private Health Insurance
This type of health insurance is health insurance coverage provided by private health insurance companies and healthcare providers, and paid for by private individuals (the insured)
Public, or Government Health Insurance
With this type of insurance, the state subsidizes healthcare in exchange for a premium.
Insurance Plans
Managed care plan
In a managed care plan, the insurer partners with healthcare providers to provide lower cost medical care to its policyholders. There will be penalties and additional costs added to out-of-network hospitals and clinics, but they will provide some treatment.
The more expensive and comprehensive the policy, the more flexible it is likely to be with the network of hospitals.
Indemnity, or Fee-for-Service Plan
A Fee-for-Service plan covers treatment equally among all providers, allowing the policyholders to choose their preferred place of treatment. The insurer may pay up 80% of costs on an indemnity plan, while the insured foots the remaining costs as a coinsurance.
Health Maintenance Organization Plans
These are organizations that provide medical care directly to the insured. The policy usually has a dedicated primary care physician or clinic that will offer all necessary care.
Health Maintenance Organization (HMO) plans will usually only fund treatment referred by a family doctor and will have negotiated fees for each medical service to minimize costs. This is usually the cheapest type of plan.
Preferred Provider Organization Plans
A Preferred Provider Organization (PPO) plan is similar to an indemnity plan as it allows the insured to visit any doctor of their choice. The PPO plan also has a network of approved providers with an agreed costs.
The insurer will pay less for treatment with out-of-network providers. However, people with a PPO plan can choose to see specialists without visiting the primary care physician.
Point-of-Service Plans
A Point-of-Service plan combines HMO plan and PPO plan. The policyholders can choose between receiving all healthcare services through a primary care physician, within the insurer’s provider network, and using non-network providers. The type of plan determines the progress of treatment and individual receives.
List of Health Insurance Companies in South Africa
- Affinity Health
- Cape Medical Plan
- Cheap Funeral Insurance South Africa
- CompCare Medical Scheme
- Day1 Health
- Discovery Health Medical Scheme
- Essential Med
- GetSavvi Health – Affordable Medical
- Genesis Medical Scheme
- Jardine Lloyd Thompson South Africa
- Metropolitan Health
- Momentum Health
- Oneplan Insurance
- Selfmed
- Stratum Benefits
- Suremed Health Medical Scheme