Co-payment Insurance is for Medical Aid Members

December 11, 2021

You need co-payment insurance because, depending on the plan you have – and the healthcare provider you use – your medical scheme probably will not cover your entire medical expense.

In that case you would be responsible for a co-payment.  Co-payments are the amounts you must pay from your own pocket . Think of this: it is entirely up to your medical aid (you have no say in it) what they are willing to pay toward a particular treatment or procedure. To put it bluntly, the rest of the expenses are your problem.

An Example of How Co-Payment Insurance Can Help

Specialists told a friend of mine that he would have to have his prostate gland removed due to the presence of cancerous cells. His medical aid said they would pay for a standard procedure – surgery where surgeons would cut open his entire lower abdomen.

My friend heard that there was an alternative, robotic, surgery available in Cape Town where tiny incisions would be made in four places on his abdomen and the surgeon would insert a robot. The surgeon would then conduct the operation remotely, on a screen.

However, this procedure would cost around double the amount that the standard procedure would cost. His medical aid made it clear that there would be a co-payment for my friend’s account – in this case around R40 000. My friend willingly paid the extra amount to have surgery where he could return home the day after the surgery.

 

However, if my friend had taken out co-payment cover, he would probably not have had to pay an extra cent. Of course, not every co-payment is this much. Many are far less – and some are even more expensive. Heart surgery could have you looking around for over R120 000 in cash to make a copayment.

Some of the variations are:

• in-hospital procedure or a procedure in a day clinic
• whether it includes medication or not
• the hospital and specialist(s) you use
• the hospital you use – is it in the network?
• is the specialist inside the network or outside?

 

Any time you make a free choice as to a specialist or hospital to use, there is usually a high co-payment involved. A copayment can be a percentarge of the cost of your medical expense or a fixed amount.

More Information About Co-Payments

The rules of the Council of Medical Schemes in South Africa  state that medical aids and service providers may charge a co-payment for a Prescribed Minimum Benefit (PMB).

But in that case you must use the scheme’s Designated Service Providers (DSPs) or use medicine on the scheme’s medicine formulary. However, if you use a different provider other than the DSP, you would have to pay a co-payment as part of the scheme’s rules.

 

Use the convenient form on this page to get a quote for co-payment insurance sign up. Don’t get caught without it.

 

All info was correct at time of publishing