Medical Aid Co-Payments

Understanding co-payments and sub-limits is essential to avoid unexpected medical costs when using your medical aid. These features can significantly impact your out-of-pocket expenses, even on higher-tier plans.

What Are Co-Payments?

Co-payments are amounts you must pay out-of-pocket for certain medical services, procedures, or treatments, even when you have hospital or day-to-day cover. Common situations requiring co-payments include:

• Elective surgeries at non-network hospitals
• Specialist consultations exceeding plan limits
• Advanced imaging like MRIs or CT scans
• Emergency services in a private hospital outside your network

Co-payments are usually a fixed fee or a percentage of the total cost and are clearly stated in the plan’s benefit brochure.

What Are Sub-Limits?

Sub-limits are maximum amounts a medical scheme will pay for specific procedures, treatments, or categories within your plan. For example:

• R10,000 per year for MRI scans
• R2,500 per year for specialist consultations
• R500 per dental procedure

Once the sub-limit is exceeded, any additional costs must be covered by you, unless you have a separate medical savings account or top-up cover.

How Co-Payments and Sub-Limits Affect Your Plan

Even if you pay high monthly contributions, co-payments and sub-limits can create unexpected expenses. Understanding these aspects is essential when comparing medical aid plans, as they can influence your overall healthcare costs.

Tips to Minimise Co-Payments and Sub-Limit Risks

• Always check the benefit brochure for co-payments and sub-limits before joining a plan.
• Use in-network hospitals and designated service providers (DSPs) where applicable.
• Consider plans that include day-to-day savings accounts to cover potential co-payments.
• Opt for higher-tier plans if you anticipate frequent specialist visits or advanced imaging needs.
• Plan procedures in advance and confirm coverage with your scheme to avoid surprises.

Frequently Asked Questions

What is a co-payment on a medical scheme?

A co-payment is a fee you must pay out-of-pocket for certain services, even if they are covered by your medical aid.

What is a sub-limit?

A sub-limit is the maximum amount a medical scheme will pay for a specific treatment or service within your plan.

Can I avoid co-payments?

Yes. Using in-network hospitals, designated service providers, or staying within sub-limits can prevent co-payments.

Do all plans have sub-limits?

Most plans have sub-limits for specialist consultations, diagnostics, and certain procedures. Premium plans usually have higher limits or none for key services.

How can I plan for co-payments and sub-limits?

Review the plan’s benefit brochure, use savings accounts, and consult with your scheme before scheduling procedures to ensure you are financially prepared.