When making a claim, a MediShield policyholder should be aware of how the main features of MediShield work: the claimable limits, deductible and co-insurance
Claimable Limits refers to the portion of your patient bill that is eligible for reimbursement. Your Claimable Limit, or claim amount, is determined by the maximum limits per day of hospitalisation, surgical procedures, surgical implants, and approved specific treatments and outpatient treatments.
A deductible is the initial amount you need to pay for claim(s) made in a policy year, before MediShield coverage starts. No reimbursement would be made from the MediShield below this claim amount. You only need to pay the deductible once in a policy year. The deductible helps to sieve out small claims, which can be paid using Medisave and/or cash, and keeps MediShield premiums affordable.
For approved outpatient treatments claimable under MediShield, the deductibles are waived and a 20% co-insurance is applicable. Some examples are outpatient chemotherapy, radiotherapy and kidney dialysis treatment.
If you choose to stay in a Class C ward during your hospitalisation, the applicable deductible would be $1,000. For Class B2 and above wards, the applicable deductible would be $1,500.
Co-insurance is the percentage of the bill you need to pay on the portion of the bill above the deductible. Co-insurance for inpatient bills is three-tiered, ranging from 20% to 10% as the bill size increases, i.e. the larger your bill, the lower the co-insurance that you need to pay. MediShield will pay between 80% - 90% of the claim amount that exceeds the deductible (if applicable).
The yellow portion of the diagram below shows what is payable by MediShield. The orange parts are the portions payable by the MediShield policyholders either via cash or Medisave.
The table below summarises the deductibles and co-insurance that are applicable for different bill sizes.
DEDUCTIBLE & CO-INSURANCE* |
| Ward Class | Day Surgery |
Class C | Class B2 & Above |
Deductible
Per Policy Year
(aged 80 and below next birthday) | $1,000 | $1,500 |
Deductible
Per Policy Year
(aged 81 to 85 next birthday) | $2,000 | $3,000 |
Co-Insurance | Claimable Amount
$1,001 - $3,000 : 20%
$3,001 - $5,000 : 15%
Above $5,000: 10% | Claimable Amount
$1,501 - $3,000 : 20%
$3,001 - $5,000 : 15%
Above $5,000: 10% |
* For outpatient treatment, the deductible is waived and a 20% co-insurance applies.
MediShield is designed to help Singaporeans pay their hospital bills incurred in subsidised Class B2/C wards. Thus, bills incurred in Class A, B1 or B2+ wards in restructured hospitals, as well as bills incurred in private hospitals, are pro-rated and not fully covered. Members who receive reduced subsidies in B2/C wards will also have their bills pro-rated to the full-subsidy bill size.
Example:
A patient staying in Class C incurs a bill of $8,000. If all the expenses are within the MediShield claimable limits (A), the total claimable amount is $8,000.
(B) Deductible
As he is staying in a Class C ward, the deductible payable by the policyholder is $1,000.
(C) Co-insurance
The co-insurance he has to pay is computed as follows:
- 20% of the claimable amount from $1,001 to $3,000: 20% x $2,000 = $400
- 15% of the claimable amount from $3,001 to $5,000: 15% x $2,000 = $300
- 10% of the claimable amount above $5,000: 10% x $3,000 = $300
Hence, the total co-insurance payable is $1,000 (i.e. $400 + $300 + $300).
The above computation is illustrated in the diagram below.
Final MediShield payout
Out of the total $8,000, the patient will need to pay $2,000 ($1,000 for deductible and $1,000 for co-insurance) by Medisave or cash.
MediShield pays the balance, i.e. $6,000, or 75% of the total bill.
For an estimate of how much you can claim from MediShield, please visit the CPF Board’s website:
https://www.cpf.gov.sg/cpf_trans/ssl/medicalEnh/medi_calc_step1.asp