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Would You Like the Security of Medical Aid Without Worrying about Co-payments?


Most South Africans could not afford private healthcare without medical aid, but some schemes require co-payments, often leaving them in debt. Members are often confused when called upon to contribute towards the cost of their treatment. The terms of their agreement stated that their scheme undertakes to reimburse 100 per cent of the cost of the treatment they received. So why should they need to pay more?

Firstly, medical aid schemes are non-profit companies, and their conduct is closely monitored by a regulatory body known as the Council for Medical Schemes (CMS). The apparent disparity between promise and practice is not the result of any unfairness by the scheme. In practice, it stems from a simple but widespread misunderstanding by most fund members.


Understanding How Medical Aid Claims are Calculated

The Department of Health (DOH) sets a recommended tariff for each service, from specific surgical procedures and medications to dentistry, physiotherapy, lab tests, X-rays and other forms of medical imaging. However, it must be emphasised that these figures are only recommendations. As the law stands, doctors, surgeons and other healthcare professionals in South Africa are under no obligation to abide by these suggested tariffs.

In practice, however, many choose to charge double or triple the DOH tariffs or even more. Consequently, many South Africans find themselves faced with unexpected co-payments. If your scheme offers to pay 200 or 300 per cent of the cost of specified benefits, the weighting applies not to a given service provider’s actual charges but to those recommended by the Department of Health. While these additional charges are, therefore, a fact of life, there are ways to avoid them or, at least, to help you pay for them.


How to Get Some Help with Your Medical Aid Co-Payments

The gap between the amounts paid to them from claims and their service providers’ charges can be substantial for a family with a constant need for private healthcare. For a relatively small sum, many schemes in South Africa offer their members the option to purchase “gap cover”. This optional add-on facility is intended to meet most, if not all, of the additional expenses when a member may be subject to co-payments.

Generally, surgery and any illness that requires hospitalisation generate the biggest bills and frequently include substantial co-payments. In South Africa, short-term insurance companies offer a product known as a hospital cash plan. Those should not be confused with the far more comprehensive hospital plans available from medical aid schemes. While the latter is intended to cover all or most of the cost involved, cash plans merely pay the policyholder a fixed cash sum for each day spent as an in-patient. These payouts won’t even come close to covering the cost of treatment and accommodation but can be a help with incidental expenses. Because the premiums are low, some people purchase a hospital cash plan to provide them with gap cover should they require costly in-patient treatment.


How KeyHealth Medical Aid Scheme Overcomes the Co-Payment Issue

South Africa’s medical aid schemes must have enough members to ensure their premium income is sufficient to settle their claims and retain at least 25% of their annual income in reserve. It is, therefore, in their interest to ensure that co-payments will not become a deterrent that might see members switching. However, premium prices must also be realistic if members are to receive the financial support they require. KeyHealth has adopted two approaches to tackle this issue. The first is to keep products as affordable as possible. For those with good general health, whose primary concerns are accidents and medical emergencies, there is a range of comprehensive hospital plans with additional benefits. Equilibrium includes a savings account which could be used to meet co-payments or day-to-day expenses if necessary.

As explained earlier, the DOH can prescribe recommended tariffs but cannot enforce them. However, because private healthcare professionals can set their own fees, they are equally free to compromise when it is in their interest. KeyHealth has leveraged this opportunity to recruit a network of preferred service providers whose agreed tariffs are fully met by the scheme without co-payments. Members remain free to select other providers if they wish, but total remuneration can no longer be guaranteed.

Times are tough, and we all need to make cutbacks, but that shouldn’t mean compromising on medical cover. Click here to learn how KeyHealth can save you money with a comprehensive range of medical aid products free of co-payments.