To maintain plan affordability

Co-payments help keep monthly premiums within manageable ranges for all members.

To encourage responsible healthcare utilisation

By sharing the cost, co-payments can encourage clients to choose cost-effective options like network providers or generic medications to the benefit of all members.

Doctors’ fees exceed tariffs

If a provider’s fees exceed Medihelp’s approved rates, clients are responsible for the difference.

Benefit allocation is less than 100%

Co-payments apply when Medihelp’s coverage is less than 100%, like in the case of original acute medicine or where set limits for medical appliances are exceeded.

Choosing non-designated service providers

Using providers outside the network often results in co‑payments.

Procedure-specific co‑payments

Some procedures come with specific co‑payments amounts that are outlined in the plan rules.

Admission co-payment

Planned hospital admissions often require an upfront co-payment.

A thorough understanding of Medihelp plans and rules is crucial for effective cost management. Resources like the Medihelp website, the Adviser Toolbox, the Adviser Guide, and regular training and information sessions provide information about day-to-day benefits, hospital networks, and pre-authorisation requirements. By being well informed, you can provide valuable advice to your clients on how to make the most of their cover while avoiding unexpected out-of-pocket expenses.  

Encourage your clients to use network providers, including doctors, specialists, hospitals, and pharmacies. These providers have pre-negotiated rates with Medihelp, often resulting in reduced co-payments compared to out-of-network providers. Assist clients to locate network providers by using network directories and online search tools.

Certain plans offer access to DSPs and healthcare providers with pre-agreed fees for specific services. Using DSPs can significantly minimise or even eliminate 
co-payments for your clients and help streamline billing processes.

Not all medical procedures require overnight hospital stays. Often, a day clinic can provide the same level of care at a significantly lower cost, resulting in reduced co-payments. Your clients can save up to 35% on co-payments by opting for day procedures at a Medihelp DPN facility.

Pre-authorisation is essential for planned hospital admissions and is often required for other services, such as chronic medication, prescribed minimum benefit (PMB) services, or specific diagnostic tests. Encourage your clients to consult the Member Zone for a comprehensive list of services requiring pre-authorisation to avoid unexpected co-payments.

Clients on plans like MedMove!, MedVital Elect, MedAdd Elect, and MedElect need to obtain referrals from network general practitioners (GPs) before consulting specialists. Without a referral, there may be a 35% co-payment on the specialist’s account. Ensure that clients obtain referral numbers before visiting specialists. Encourage them to discuss this requirement and any specific recommendations or limitations regarding specialists within the network with their GP during their initial consultation.

While Medihelp plans offer comprehensive coverage, out-of-pocket expenses can still arise due to factors like specialist shortfalls and co-payments. Gap cover acts as a financial safety net by bridging the gap between what your client’s medical aid pays and the actual cost of certain healthcare services, offering additional peace of mind.

Encourage clients to consider generic medications whenever they are available. These alternatives are as effective as their brand-name counterparts but are significantly cheaper. Medihelp recognises this advantage and covers 100% of the Maximum Medical Aid Price (MMAP) for generic medicines.

Additionally, on plans such as MedMove!, MedVital Elect, MedAdd Elect, and MedPrime Elect, the concept of “formulary medicine” comes into play. A formulary is a curated list of preferred medicines chosen by Medihelp based on their safety, effectiveness, and cost-effectiveness. Opting for formulary medicine can lead to further cost savings.