26 May 2023

medical aid co-payments card machine

Medical Aid Co-Payments Explained

There are many different types of medical aid co-payments for treatments and procedures that your medical aid might need you to pay for yourself.

Certain co-payments are listed as deductibles which requires an upfront payment to the hospital or specialist doctor.  This would mostly be for specific treatments or procedures, or when you choose to use a hospital or doctor outside of the required medical aid network.

The co-payment can either be a stated fixed Rand value amount or a percentage of the cost.

The amounts could vary due to the type or place of healthcare service provider used or by the rate charged by the healthcare service provider.

Why do we have co-payments?

Co-payments are a requirement to ensure the ongoing sustainability of a medical aid.

As required by legislation, all medical aid contributions must go into a combined pool of funds.  These funds must be managed carefully to ensure that the funds are spent responsibly. Therefore, measures are in place to manage and control the spending of these funds.

Co-payments are not only imposed on members to consider the necessity of benefits before using them. It is also to keep the overall usage of the combined pooled funds down. In turn, this means lower annual premium increases and more competitive premiums.

What are the different types of medical aid co-payments?

Admission co-payment: An admission co-payment is an amount a medical aid requires you  to pay prior to admission for a planned in-hospital event.

Procedural co-payment: A procedural co-payment is relevant to certain specialised procedures or treatments identified by your medical aid option. Some of these specialised procedures or treatments could be performed either in the doctors’ rooms, in a day-hospital or a hospital.

Penalty co-payment: A penalty co-payment is an amount you must pay for the voluntary use of non-designated (non-network) service providers for planned medical events. Certain medical aids will impose a penalty co-payment for late authorisation requests after an event has already taken place.

Chronic cover co-payments: You will experience a chronic benefit co-payment when the prescribed treatment for your condition does not fall within the approved formulary and when you make use of a non-designated pharmacy provider when obtaining monthly medication.

A formulary is a list of scheme and option approved drugs covered for chronic conditions. Each condition listed under the chronic benefit has a formulary of chosen drugs and Rand amounts which the schemes contribute towards for approved registered conditions.  Each scheme has their own defined formularies and there isn’t an industry standard per condition.

When do co-payments not apply?

  • In the event of a medical emergency none of the above co-payment types should apply to members. A medical emergency would be the sudden and, at the time, unexpected onset of a health condition which could result in weakened bodily functions, serious and lasting damage to organs, limbs, or other body parts or even loss of life if not treated immediately.
  • When a member voluntarily makes use of a non-designated service provider due to the following reasons:
    • The designated service provider is unable to accommodate or treat the member.
    • When there is no designated service provider available in a reasonable distance from the members’ place of work or home.
  • If the prescribed treatment for an approved chronic condition is outside the appropriate protocols and the treating doctor can provide clinical information and history that the formulary drugs were ineffective or detrimental to a member’s condition, the medical scheme must pay for this treatment without any co-payments.

How can you avoid or reduce co-payments?

Although co-payments are needed to help keep medical aid premiums down, the below tips will help you avoid or minimise medical aid co-payments.

  1. By making use of your scheme’s various network service providers for planned medical events.
  2. By choosing to make use of a day-hospital or doctor’s room for procedures or treatment if and where possible.
  3. By approaching your treating doctor to reassess your prescribed treatment for any approved chronic conditions to fall within your scheme option formularies.
  4. By taking out a gap cover policy that covers certain co-payments.

Zestlife’s Gap Cover policy provides co-payment cover for hospital admissions, CT, PET and MRI scans and specified medical procedures.  See our brochure for details of benefits and terms and conditions.

Contact HealthMax if you need help understanding your medical aid benefits.

The information contained in this communication, including attachments, is not to be construed as advice in terms of the Financial Advisory and Intermediary Services Act of 2002 (“FAIS”) as the writer is neither an appointed representative of Zestlife, nor a licensed financial services provider as contemplated in FAIS. Please consult your Financial Adviser or Zestlife should you require advice of a financial nature and/or intermediary services.