What is a co-payment?
Members join a medical scheme to ensure that they will be taken care of when they require healthcare services, should they ever be faced with a medical condition or emergency. Schemes are able to provide such protection by utilising the combined funds built up through the careful management of members’ contributions. Thus, it is crucial that funds are spent responsibly, and that there are measures in place to help control and manage the spending of members’ combined pool of funds. This document is aimed at helping members understand the role co-payments play in protecting them and ensuring the ongoing sustainability of a scheme.
The Council for Medical Schemes (CMS) is the regulatory body for medical schemes in South Africa. It aims to protect the members of medical schemes. Any co-payment that the medical scheme applies is included in the Scheme Rules which are approved by the CMS. Co-payments do not apply to emergency treatment and are waived in certain instances for Prescribed Minimum Benefits.
A co-payment works on the same principle as an excess on your car or home short-term insurance, in that scheme members pay a specified portion of the medical bill, and the scheme pays the remainder.
This co-payment can be funded from:
- available medical savings upon request,
- available HealthSaver+ funds upon request, or
- the member’s own pocket.
Principle of applying co-payments
Medical schemes work on the principle of pooling of funds - all members’ contributions are pooled together. The benefit of pooling is that you have access to all members’ contributions when you really need it, not just your own. The potential negative impact of pooling is that not everyone is as responsible with utilising these funds. Members could potentially misuse the pooled funds if they are not encouraged to consciously make decisions that are responsible and consider the necessity of benefits before using them. When members have to pay co-payments, there is less likelihood of unnecessary claiming or use of benefits.
A fixed co-payment should ideally be significant enough for members to consider whether they really need to use a particular benefit, but small enough not to cause financial distress if the healthcare service is necessary. This encourages members to manage their spending of the pooled funds and in that way, co-payments help to keep the overall usage on the pooled funds to appropriate and relevant levels. This, in turn, keeps members’ contributions as low and competitive as possible.
Fixed co-payments are usually applied to benefits that are easy targets for possible unnecessary spending or over servicing. These are determined by analysing stakeholder behaviour, such as members, hospitals, GPs and specialists, to see where there are high increases in the use of specific benefits that cannot be linked to the health status of members. In addition, where the scheme has contracted with certain providers, such as a hospital network, for discounted fees, variable co-payments will be charged when members voluntarily use non-contracted providers from whom the scheme does not receive negotiated rates.
The major co-payments
Co-payments are set at different levels for the various options on Momentum Medical Scheme and apply to various benefits.
Below are the most common co-payments:
| Ingwe | Evolve | Custom | Incentive and Extenderr | Summit | |
Hospital admissions | None | R2 000 co-payment applies per authorisation, including for non-emergency Prescribed Minimum Benefits, except for motor vehicle accidents, maternity confinements and emergency treatment. Co-payments for specialised procedures listed below. | R2 000 co-payment applies per authorisation, including for non-emergency Prescribed Minimum Benefits, except for motor vehicle accidents, maternity confinements and emergency treatment. Co-payments for specialised procedures listed below. | None, except for specialised procedures listed below. | None |
| In-hospital dentistry | Maxillo-facial trauma covered at State facilities, limited to Prescribed Minimum Benefit. | Maxillo-facial trauma covered at State facilities, limited to Prescribed Minimum Benefits. | Maxillo-facial surgery (excluding implants) and general anaesthesia for children under 7: R2 000 co-payment per authorisation. | Maxillo-facial surgery (excluding implants) and general anaesthesia for children under 7: R1 820 co-payment per authorisation. | None |
| Extraction of impacted wisdom teeth in hospital | Not covered | Not covered | R3 600 co-payment for day hospitals and R6 800 co-payment for other hospitals, per authorisation. | R3 600 co-payment for day hospitals and R6 800 co-payment for other hospitals, per authorisation. | None |
| Extraction of impacted wisdom teeth in doctor’s rooms | Not covered | Not covered | R2 000 per authorisation | R1 820 per authorisation | None |
| MRI and CT scans in- and out-of-hospital | If you choose Connect Network hospitals, MRI and CT scans are limited to Prescribed Minimum Benefits at Connect Network hospitals and other specialised scans are subject to Prescribed Minimum Benefits at State facilities. If you choose Ingwe Network hospitals or Any hospital, all scans are limited to Prescribed Minimum Benefits at State facilities. | R3 850 per scan | R3 850 per scan | R3 500 per scan | R3 500 per scan |
Specialised procedures and treatment co-payments
| How specialised procedures and treatment are covered on the Evolve Option | |
| The standard Evolve Option co-payment of R2 000 per authorisation applies to these procedures and treatments regardless of where they are performed Plus the specialised procedures co-payment of R5 500 per authorisation applies if performed in an acute or day hospital. | |
| Arthroscopies, Back and neck surgery*, Carpal tunnel release, Functional nasal and sinus procedures, Joint replacements*, Laparoscopies | Performed in a day hospital or acute hospital, subject to the relevant co-payment listed above |
| Gastroscopies, Colonoscopies, Cystoscopies, Sigmoidoscopies, Nail surgery, Removing of extensive skin lesions | Performed out of hospital, in a day hospital or in an acute hospital, subject to the relevant co-payment listed above |
| Conservative back and neck treatment*, Removal of minor skin lesions, Treatment of diseases of the conjunctiva, Treatment of headache, Treatment of adult influenza, Treatment of adult respiratory tract infections | Low severity cases are not covered by the Scheme but can be paid from HealthSaver+, if available
High severity cases in an acute hospital are paid by the Scheme, subject to the relevant co-payment listed above |
| How specialised procedures and treatment are covered on the Custom Option | |
| The standard Custom Option co-payment of R2 000 per authorisation applies to these procedures and treatments regardless of where they are performed Plus the specialised procedures co-payment of R2 000 per authorisation applies if performed in a day hospital, or R5 500 per authorisation if performed in an acute hospital (hospital where overnight admissions apply). | |
| Arthroscopies, Back and neck surgery, Carpal tunnel release, Functional nasal and sinus procedures, Joint replacements, Laparoscopies | Performed in a day hospital or acute hospital, subject to the relevant co-payment listed above |
| Gastroscopies, Colonoscopies, Cystoscopies, Sigmoidoscopies, Nail surgery, Removing of extensive skin lesions | Performed out of hospital, in a day hospital or in an acute hospital, subject to the relevant co-payment listed above |
| Conservative back and neck treatment, Removal of minor skin lesions, Treatment of diseases of the conjunctiva, Treatment of headache, Treatment of adult influenza, Treatment of adult respiratory tract infections. | Low severity cases are not covered by the Scheme but can be paid from HealthSaver+, if available
High severity cases in an acute hospital are paid by the Scheme, subject to the relevant co-payment listed above |
| How specialised procedures and treatment are covered on the Incentive and Extender Options | |
| A co-payment of R2 000 per authorisation applies to these procedures and treatments if performed in a day hospital
Or a co-payment of R5 500 per authorisation applies to these procedures and treatments if performed in an acute hospital (hospital where overnight admissions apply). | |
| Arthroscopies, Back and neck surgery, Carpal tunnel release, Functional nasal and sinus procedures, Joint replacements, Laparoscopies | Performed in a day hospital or acute hospital, subject to the relevant co-payment listed above |
| Gastroscopies, Colonoscopies, Cystoscopies, Sigmoidoscopies, Nail surgery, Removing of extensive skin lesions | Performed out of hospital, in a day hospital or in an acute hospital, subject to the relevant co-payment listed above |
| Conservative back and neck treatment, Removal of minor skin lesions, Treatment of diseases of the conjunctiva, Treatment of headache, Treatment of adult influenza, Treatment of adult respiratory tract infections. | Low severity cases are not covered by the Scheme but can be paid from Day-to-day Benefits or HealthSaver+, if available
High severity cases in an acute hospital are paid by the Scheme, subject to the relevant co-payment listed above |
Important notes
- You need to obtain pre-authorisation from Momentum Medical Scheme at least 48 hours before you or your dependants are admitted to a hospital or day clinic, receive treatment covered under the specialised procedures/treatment benefit, Major Medical Benefit or have a specialised scan.
- If you do not get pre-authorisation in time, you will need to pay a 30% co-payment on all accounts related to the claim event and the Scheme would be responsible for 70% of the negotiated tariff, provided authorisation would have been granted according to the Rules and protocols of the Scheme. This is in addition to any other co-payments that apply.
- In the case of an emergency, you, a family member or a friend may obtain authorisation within 72 hours of admittance.
- Ingwe Option: If you choose Ingwe Network hospitals or Connect Network hospitals and do not use this provider, you will have a co-payment of 30% on the hospital account.
- Evolve Option: If you do not use Evolve Network hospitals, you will have a 30% co-payment on the hospital account.
- Evolve and Custom Options: these options have standard option co-payments which apply to all admissions including non-emergency Prescribed Minimum Benefit treatment.
- Custom, Incentive and Extender Options: If you choose Associated hospitals and do not use this provider, you will be liable for a 30% co-payment on the hospital account.
To confirm if co-payments are applicable to an option, please check your member guide for more details. You are also welcome to contact us via WhatsApp on 0860 11 78 59, web chat on momentummedicalscheme.co.za, email at [email protected], or call 0860 11 78 59.
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Disclaimer: +Momentum Medical Scheme members may choose to make use of additional products available from Momentum Group Limited and its subsidiaries as well as Momentum Multiply (herein collectively referred to as Momentum). Momentum is not a medical scheme and is a separate entity to Momentum Medical Scheme. Momentum products are not medical scheme benefits. You may be a member of Momentum Medical Scheme without taking any of the products offered by Momentum.