Co-Payments And Beyond
Photo by Jordan Rowland on Unsplash

Photo by Jordan Rowland on Unsplash

How do co-payments work, why are they necessary and how best can they be reduced or avoided altogether?

When choosing a medical scheme or a new product option it is all-important to consider your benefits, co-payments and finer details surrounding these benefits, along with the cost thereof.

By looking at the cost of the cover you are intending to buy in isolation, you may well be selling yourself short further down the line. Here are a few pointers that will ensure that you are not left out of pocket unnecessarily.

Make sure you understand your medical scheme and its different benefit options. Read the membership guide and product brochures to familiarise yourself with the option’s benefits. If you do not understand certain benefits or rules, please insist on a comprehensive explanation from your healthcare broker or directly from the scheme.

Remember, the membership guide will not only give you important information regarding general procedures to be followed, but it will also provide you with very specific information regarding the extent of medical cover available to you.

You should also check what exactly you are covered for from the outset. The scheme benefits may place limitations on benefits and that is why you should check that the benefits offered will meet your specific requirements as well as those of your dependants.

CompCare has an extensive range of 11 product options on offer for you to choose from. When evaluating the different products you will find that the more benefits you have, the more the option you select is likely to cost you.

You will find that CompCare, like most other medical schemes, will provide some options where ‘co-payments’ apply when it comes to certain medical procedures. This is done to reduce the overall monthly premium of the option you have chosen.

What exactly are co-payments and when do they come into play?

There is a great deal of confusion surrounding the question of co-payment. However, in a nutshell, a co-payment is the amount that you are personally responsible for paying towards a specific healthcare procedure and/or treatment that you may require.

There are a number of factors that will influence the amount that you have to pay from your own pocket and, interestingly enough, there are also ways that you can reduce the amount that you have to pay.

What determines your co-payment?

The personal circumstances that you and your dependants find yourselves in will play an important role when it comes to co-payments. According to the Council for Medical Schemes (CMS), if your scheme appoints a designated service provider and you choose to use a provider other than a designated one, you could be responsible for covering the difference between the actual cost and what the medical scheme would have paid if you had used the designated service provider.

Co-payments are typically required when more costly medicines, that are not part of the scheme medicines formulary, are used. They also apply in the event of certain in-hospital procedures or when members choose to make use of out-of-network hospitals, specialists and even general practitioners.

How can you reduce your co-payments?

The advantage of visiting a network doctor, specialist or a network hospital is that an agreement has been made between the medical scheme and the designated healthcare service provider to render quality, cost-effective care at an agreed medical scheme tariff. In such instances, members are generally not required to make any co-payments. In addition, where possible you should make use of generic medicines or medicines from the CompCare formulary to ensure that you will not have to make a co-payment. According to the CMS, your scheme cannot hold you responsible for a co-payment or levy on a prescribed minimum benefit (PMB) as long as you use the designated service providers of the scheme.

Why CompCare is a cut above the rest

Did you know that CompCare’s 2020 benefits enhancements include an unlimited cancer treatment programme? In addition, benefits that are funded from risk include mammograms, oral contraceptives, private casualty benefits, surgical and medical appliances as well as a wide range of wellness benefits and childhood vaccinations. CompCare Wellness also funds hormone replacement therapy (HRT) on all its options and is one of the few medical schemes to cover professional sportsmen and women. It offers unlimited general practitioner and basic dentistry benefits and covers attention deficit disorder (ADD) treatment on selected options. Laser eye surgery is covered on the Pinnacle, Dynamics and Symmetry options while the CompCare NetworX option remains the most affordable network option on the market. In closing, it is important to remember that sometimes cost alone will determine what option and which scheme you can afford to belong to. However, when comparing the different costs of medical scheme benefit options please make sure that you are comparing apples with apples and that you take into account all the necessary benefits. It is always better to choose the cover that is most appropriate to meet your needs and your pocket.