What is CoPay Cover and Do You Need It?


The soaring cost of health care in South Africa has forced medical aid schemes to introduce cost sharing mechanisms.

Along with monthly contributions, scheme members of more affordable plans are now expected to cover a portion of the costs of certain medical treatments and procedures - up front, and from their own pocket.

What is a copay? 

In South Africa, an out of pocket expense levied on medical aid scheme members is known as a copay or copayment.

Depending on the level of cover, a copay can apply to a wide range of services - hospital admissions, MRI and CT scans, specialist consultations, lab work, prescribed medication, the voluntary use of non-network service providers, and so on.

As a member of a low- to mid-cost medical aid plan, you’ll be expected to pre-pay for specified health care services, conducted in and out of hospital. 

If you don’t have copay cover, and your budget doesn’t extend that far, you’ll have to do without the treatment or surgery. The only other alternative is to rely on the dysfunctional public healthcare service, instead.

Copayment vs coinsurance

In South Africa, a copayment is either levied as a fixed fee or as a percentage of the total cost of a particular health care service or procedure. 

Although ‘copayment’ is a generic term used in South Africa, it actually applies to the fixed fee model of cost sharing.

‘Coinsurance’, on the other hand, is the correct term for the percentage-based system imposed on medical aid scheme members.

Copayment vs deductible 

Similarly, the term ‘copayment’ and ‘deductible’ is used interchangeably in South Africa.

In other parts of the world, a deductible is the annual amount a medical scheme member has to personally pay towards health care before medical aid kicks in. It is similar to the excess payable in motor vehicle insurance.

Once the deductible has been paid, the scheme steps in to cover its share of the medical costs accrued for the remainder of that year. This type of cost sharing is seldom imposed in South Africa.

Now that you know the ‘copay’ from the ‘deductible’, it’s time to consider copay cover as an integral part of your financial planning. Where do you get cover for medical copayments? Here are a few of the top providers in SA.

Providers of copayment cover in South Africa 

In South Africa, there are several gap cover providers that include copay cover in their benefit structures.

At Stratum Benefits, the entry level Compact 200 plan provides R15 000 copayment cover per policy per year. Cover escalates to R50 000 on the Co-Evolution and Elite options, and there’s a non-network copay benefit of R8 500.

Liberty Health offers full cover for copayments relating to hospital admissions, scans and certain procedures on the Essential and Universal gap cover options. A non-DSP benefit of R9 300 is limited to one claim per year on the Universal plan.

Sirago has four gap cover options that offer limited copayment benefits extending from R10 000 to R16 00 per claim.

In addition, Sirago’s Exact with Copay Cover insurance policy offers copayment benefits for medical procedures that may not be covered by medical aid schemes, such as back and neck surgery, cochlear implants and joint replacement surgery.

Benefits are paid up to R15 000 per policy per year, and limited to R 8 000 per claim.

Do you need more information about copay cover? Or are you looking for a medical aid scheme or gap cover provider in South Africa? Call IFC on 021 593 3012 and we’ll help you find the best possible cover for your family’s healthcare requirements and budget.

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