Medical schemes are designed to help members cover private medical expenses, but the extent of that cover depends on a number of factors, including the medical scheme you join, the benefit option you choose, and the healthcare providers you use.
If a medical scheme plan does not cover 100% of the costs of a medical expense, the member will be liable for a co-payment. This could be a hospital co-payment, a co-payment to a specialist, or even co-payments for certain medications.
The percentage of the fee that the member is liable for is usually associated with the benefit option that a member chooses and the service providers they use, as different healthcare service providers do not charge according to medical aid rates but set their own fees.
When do co-payments not apply?
The Council of Medical Schemes in South Africa has mandated that Prescribed Minimum Benefits (PMBs) may not carry co-payments if a medical scheme’s Designated Service Providers (DSPs) and medicine formulary are used. However, if a member chooses to use a provider that is not a designated provider, they may be liable for a co-payment as well.
How to avoid co-payments
- Take out gap cover
Even though Profmed provides unlimited benefits for hospitalisation, the tariffs charged by some surgeons, anaesthetists and other specialists may be higher than the tariffs covered by Profmed.Typical shortfalls can be anything from R37 000 for a Caesarean Section Childbirth, to over R55 000 for shoulder surgery. Cancer treatments and heart surgeries result in the highest self-payment gaps, with most patients facing well over R100 000 in out-of-pocket expenses. These costly out-of-pocket hospital and specialist expenses can be avoided through gap cover.Gap cover is an insurance benefit that protects medical aid members against medical expense shortfalls. Like all short-term insurance products, you pay a monthly premium.Find out more about Profmed’s PPS Gap Cover
- Use a network hospital
Our Savvy options offer all the benefits of the plan you’re on but you choose to use a network hospital that has agreements in place with Profmed to offer reduced rates.A network hospital refers to a hospital (or group of hospitals) with which a medical scheme has an agreement, ensuring that the scheme’s rates are charged and that no co-payments are applicable.Network options typically offer the same benefits as other service providers, but within a defined network of healthcare professionals and facilities. The agreements that Profmed has with these providers allows us to pass on discounted costs and therefore lower monthly contributions. If a member chooses a network option, they also don’t pay co-payments.For example, our Savvy options offer members a large selection of network hospitals to choose from when requiring hospitalisation at a 10% premium discount. However, a R10 000 co-payment applies if a member on a Savvy option chooses to use a non-network provider. This copayment essentially amounts to what was saved in premiums by being on the Savvy network.Our ProSelect option offers a broader network, giving members a wider choice of hospitals to choose from. We have carefully selected the list of hospitals to ensure we provide members access to the most efficient hospitals with the best clinical outcomes. The list of hospitals on the network must be carefully considered when remaining on, or selecting this option. If a member is voluntarily admitted to a non-network hospital, you will be responsible for a co-payment as well.Review all Profmed Savvy options
- Choose a Day Clinic where possible
Procedures that can be done at day clinics instead of hospitals can cost up to 30% less, with the same clinical outcomes. To be referred to a day clinic, you will need to speak to your doctor.To avoid co-payments, Profmed has introduced the Day Procedures Network on our ProActive Plus, ProSecure and ProSecure Plus options. We have negotiated preferential rates for specific day procedures that previously would have required in-hospital stays.At Profmed, we are excited about this shift in how we approach procedures, because they often mean a lower risk of hospital-acquired infections and earlier discharges to go home. This is also supported by our home care initiative Healing@Home, where members can recuperate from the comfort of their own homes under medical supervision.View our day procedure network
