Co-Payment Cover - A Beginners Guide
Co-Payment Cover, A Beginners Guide in South Africa revealed.
We verified the best Co-Payment Beginner Guide in South Africa.
This is a complete guide to Co-Payment Cover in South Africa.
In this in-depth guide you’ll learn:
- ☑️ What is Co-Payment Cover?
- ☑️ How do you find affordable co-payment coverage?
- ☑️ How does hospital co-payment cover work?
- ☑️ How do medical scheme co-payments work?
So if you’re ready to go “all in” with the best guide to co-payment cover in South Africa, this guide is for you.
Let’s dive right in…
Co-Payment Cover – A Beginners Guide Summary
👉 Medical schemes are intended to help members cover private medical expenses. The amount to which a medical scheme will cover its members’ private medical expenses is determined by a variety of factors, including the medical plan that you join, the benefit choice that you select, and the healthcare providers that you use.
👉 A co-payment may be required of a member of a medical insurance plan in the event that the plan does not cover the whole cost of a particular medical expense. This could be a co-payment for a specialist visit, a co-payment for a hospital stay, or even a co-payment for specific prescriptions.
👉 As a result of the skyrocketing costs of medical care in South Africa, medical aid programmes have been obliged to implement cost-sharing systems.
👉 Because different healthcare service providers do not charge according to medical aid rates but rather set their own costs, the percentage of the fee that the member is responsible for paying is typically tied to the benefit option that the member selects as well as the service providers that the member uses.
How to avoid co-payments
👉 In addition to making monthly payments, members of schemes that provide more modest plans are now obliged to pay a portion of the price of some medical treatments and procedures up front and out of their own personal funds.
👉 Co-payments can be avoided in the following ways:
Use a network hospital
👉 Some options of medical aids offer all the benefits of the plan you’re on, but you must use a network hospital that has agreements in place with the aid to offer reduced rates.
👉 The medical scheme will have an agreement with a network hospital or group of hospitals that ensures that the scheme’s rates will be charged and that no co-payments will be applicable. Such network options characteristically offer the same benefits as other service providers but within a defined network of healthcare facilities and professionals. These agreements with providers allow medical aids to pass on discounted costs, resulting in lower monthly contributions.
👉 By using a network option, members will not pay co-payments, but co-payment applies if a member on a network option chooses to use a non-network provider. The list of hospitals on a network must be thoroughly considered when selecting such an option.
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Choose a Day Clinic where possible
👉 Procedures that can be performed at day clinics rather than hospitals can have a cost savings of up to thirty percent while maintaining the same level of clinical efficacy. You will need to consult with your primary care physician in order to be sent to a day clinic.
👉 It often indicates a decreased risk of infections that are acquired in the hospital as well as earlier discharges to go home. This is also supported by home care initiatives, which allow members to rehabilitate from the convenience of their own homes while still being supervised by medical professionals.
Take out co-payment cover
👉 Even if your medical aid provides unlimited hospitalisation benefits, the tariffs charged by some surgeons, anaesthetists and other specialists may be higher than the tariffs covered by the aid. These costly out-of-pocket hospital and specialist expenses can be avoided through co-payment cover, also called Gap Cover.
☑️ READ more about 5 Best Medical Aid Co-Payment Cover in South Africa
What is a co-payment cover?
👉 Shortfalls can vary from R40 000 for a Caesarean Section Childbirth, to over R60 000 for shoulder surgery, with cancer treatments and heart surgeries causing the highest co-payment gaps, often well over R100 000 in out-of-pocket expenses.
👉 In South Africa, an out of pocket expense levied on medical aid scheme members is known as a co-pay or co-payment. For a monthly premium, Gap cover is an insurance benefit that protects medical aid members against medical expense shortfalls.
👉 Depending on the level of cover a member choose, a co-payment can apply to a varied range of services – hospital admissions, MRI and CT scans, specialist consultations, lab work, prescription medicine, the voluntary use of non-network service providers, and more.
👉 You may be required to make a down payment or prepayment for a selection of inpatient and outpatient medical treatments if you are enrolled in a medical aid programme with a low to moderate monthly premium.
👉 If you do not have co-payment cover and your budget does not stretch that far, you will not be able to afford the treatment or surgery, and you will be required to forego it. The only other choice available is to rely on the broken system that the government provides for healthcare.
Pros and Cons of Co-payment Cover
Pros
- ➡️ Eliminate financial strain in times of medical emergencies.
- ➡️ Provide benefits for your entire family if they are covered on the policy of a registered medical aid scheme.
- ➡️ Co-payment cover has no entry age limit
- ➡️ There is no waiting period for many specific procedures. These may include all emergency procedures, tonsillectomies, appendectomies, gall bladder removal, and others not explicitly excluded.
- ➡️ Except for a limited list of specific conditions and procedures, it provides immediate gap cover benefits for all policyholders.
- ➡️ Provides instant gap cover for procedures, including those where your medical aid has failed to meet the full obligation.
- ➡️ It covers Prescribed Minimum Benefits (PMBs) where a medical aid fails to meet the obligations.
- ➡️ It may offer other benefits like home drive, a panic button, and a medical and trauma counselling line.
- ➡️ It is an excellent way to protect you from several kinds of medical shortfalls.
Cons
- ➡️ Co-payment cover is not a substitute for a medical aid scheme membership.
- ➡️ Payments are subject to an aggregate gap cover annual limit that is usually less than R200 000 per insured person per annum.
- ➡️ All of them have exclusions and limitations, so when you compare medical Gap insurance options, make sure that you understand each plan’s exclusions and limitations.
- ➡️ Certain pre-existing conditions and emergency services are not covered.
- ➡️ Gap insurance also has various waiting periods before your coverage will become active. This is important if you anticipate a situation in which you might need coverage soon.
- ➡️ The policies are subject to terms and conditions.
👉 Where do you get cover for medical co-payments? There are a few of the top providers in SA.
Providers of co-payment cover in South Africa
👉 There are a few different gap cover providers in South Africa who incorporate co-pay cover within the benefit packages of their products.
👉 The entry-level Compact 200 plan offered by Stratum Benefits includes R15 000 worth of co-payment cover for each individual each year. Coverage increases to R50 000 with the Co-Evolution and Elite options, and a non-network benefit of R8 500 is included in the plan.
👉 On the Essential and Universal gap cover choices, Liberty Health provides complete coverage for co-payments related to hospital admissions, scans, and some procedures. This includes specific treatments. On the Universal plan, you are only allowed to submit one claim for a non-DSP benefit totalling R9 300 every year.
👉 There are four different alternatives for gap cover provided by Sirago. These options provide limited co-payment benefits ranging from R10 000 to R16 000 for each claim.
👉 In addition, the Sirago Exact with Co-pay Cover insurance coverage provides co-payment benefits for medical treatments such as back and neck surgery, cochlear implants, and joint replacement surgery, which may or may not be covered by medical aid programmes.
👉 Benefits are paid out at a maximum of R15 000 per policy on an annual basis, with a maximum pay-out of R8 000 per claim.
READ more about Top Hospital Plans in South Africa
Frequently Asked Questions
Is co-payment cover a good idea?
☑️ Yes, you can consider purchasing gap cover if you are worried that you won’t have a sizable sum of money ready to pay for medical expenses. Independent financial advisors and certain medical professionals concur that gap insurance is necessary for medical aids that do not fully or completely cover all costs.
What exclusions exist with co-payment cover insurers?
☑️ Gap insurance cannot be used when upfront payments must be made privately. Additionally, co-payment coverage frequently does not cover bills for the treatment of depression, emotional problems, mental illnesses, or drug or alcohol dependence unless it is covered by your PMB.
Is Co payment cover the same as a medical scheme?
☑️ Co payment is not a medical plan; it is an insurance product, and its coverage is different from a medical scheme’s.
What is the maximum age to apply for Co payment cover?
☑️ The Co Payment Cover does not have a maximum entry age and does not have a maximum expiry age. Main members and dependents of all South African medical aids that are registered have access to Gap Cover alternatives.
Does Co payment cover cover visits to General Practitioners?
☑️ No, routine doctor’s appointments or specialty services, as well as trips to the dentist and for eye exams, are not covered. These exclusions include pre- and post-procedure consultations with specialists who are not involved in inpatient or outpatient operations.
Does Co payment cover pay for blood tests?
☑️ Whether copayment cover covers for procedures like blood testing depends on your medical aid plan. Your Gap Cover will likely not pay anything if your plan does not cover pathology (blood tests). There is a good chance that your Gap Cover will pay the remaining balance if your medical aid plan only covers a portion of the cost.
Does Co payment cover pay for MRI scans?
☑️ Yes, depending on the option you selected, your co-payment coverage should cover MRI scans. You receive coverage for tariff shortfalls on in-hospital specialist claims and specific out-of-hospital costs, as well as coverage for co-payments on approved endoscopies, MRI and CT scans, and cancer-related claims. Each member or dependent may be subject to an annual cap on the total amount.
