For those who are navigating what the NHI will and will not cover, understanding these exclusions is key to making informed healthcare choices and managing additional health-related expenses. In this article, we’ll outline what the NHI won’t cover, helping you make the best decisions for yourself and your family.

Management of Healthcare Facilities

Under the NHI, the actual management of hospitals, clinics, and private practices is not covered. This means that the NHI’s responsibility will be focused on funding and purchasing healthcare services, while the daily management of these facilities will remain with the hospitals, clinics, and private health practices themselves. The system is designed this way to allow healthcare professionals and institutions to maintain operational control, while the NHI concentrates on delivering affordable, equitable healthcare access.

Services Covered Exclusively by Medical Schemes (Top-Up Services)

Once fully implemented, the NHI will provide a comprehensive package of services covering primary healthcare, hospital care, mental health services, rehabilitation, and palliative care, among others. However, private medical schemes will not be permitted to duplicate services already covered by the NHI. In other words, medical schemes will be limited to offering top-up services, which are additional benefits that fall outside the NHI’s coverage. This change is intended to prevent duplication and focus medical scheme resources on services that enhance care but aren’t covered under the public system.

For those who prefer or require specific medical treatments not included in the NHI package, private medical schemes can still offer coverage for these add-ons. This is significant for patients who may need or prefer specialized treatments, elective procedures, or upgraded services not deemed essential by the NHI.

Non-NHI Contracted Providers

An important aspect of the NHI is that it will only cover services from healthcare providers who are contracted under the NHI. This means that if a provider chooses not to participate in the NHI system, the NHI will not cover the costs of treatments from that provider.

Patients can, however, use their private medical schemes to cover these services if they prefer a specific provider not affiliated with the NHI. This could be an essential option for individuals who already have established relationships with particular doctors or specialists who opt to remain outside of the NHI framework.

Excluded Treatments and Procedures

Although the NHI plans to cover a wide array of services, there are some treatments and procedures that may fall outside its scope. While the exact list of exclusions may be refined as the NHI progresses, elective and non-essential procedures are often not included in public health coverage worldwide, and South Africa’s NHI is expected to follow a similar model. Cosmetic surgery, luxury services, and other non-medically necessary treatments are likely to be excluded. Additionally, patients seeking private rooms or services outside of standard provisions may need to fund these out-of-pocket or through supplementary medical schemes.

What the NHI Will Cover

• Primary healthcare: Preventative care, doctor visits, and outpatient services.
• Hospital services: Inpatient treatment and necessary hospital care.
• Mental health services: Access to mental health professionals and therapy.
• Rehabilitation and palliative care: Support for patients needing long-term or end-of-life care.
• Emergency medical services: Immediate treatment for acute and life-threatening conditions.
• Patient transport services: Transportation for those needing access to healthcare facilities.