Co-payments and sub-limits on medical aid: what you pay and how to avoid surprise bills

A sub-limit can bite even when your overall benefit looks healthy. If a plan caps a category and you reach that cap, you pay the rest yourself. Your plan's benefit guide and rules list them, and they vary by scheme and plan.

Regulation 8(1) says any benefit option must pay in full, without co-payment or the use of deductibles, the diagnosis, treatment and care costs of the PMB conditions. The CMS describes the PMBs as 271 conditions plus the Chronic Disease List, and any emergency medical condition is also a PMB. See our prescribed minimum benefits guide.

That protection has limits.

1. Designated service provider. Scheme rules may require you to use a DSP for PMB care and may charge a co-payment if you choose another provider voluntarily. The CMS says that co-payment could be a percentage, or the difference between the DSP's tariff and what your provider charged.
2. Protocols and formularies. Schemes may use pre-authorisation, treatment protocols and formularies for PMBs. Choosing a drug outside the formulary can attract a co-payment.

Exclusions do not apply to PMBs, so a scheme cannot refuse a PMB claim just because the plan excludes that kind of care.

No co-payment or deductible is payable if you obtained the PMB service from a non-DSP involuntarily. Regulation 8(3) treats it as involuntary when:

• The DSP could not provide the service, or would not provide it without unreasonable delay.
• You needed immediate treatment in circumstances or at a place that reasonably stopped you reaching a DSP.
• There was no DSP within reasonable proximity of your home or workplace.

In an emergency you may go to the nearest healthcare facility even if it is not a DSP, and the CMS says your scheme has to cover the costs. If a scheme charges a co-payment in these cases, dispute it in writing with the facts of the day. Our designated service providers guide explains how DSPs work.

They vary widely, but these are the usual places to look in your benefit guide:

• Planned procedures such as scopes, including gastroscopy and colonoscopy
• MRI and CT scans
• Some joint and spinal surgery
• Dental work under anaesthetic
• Using a hospital or provider outside a network plan's list
• Medicine outside the formulary
• Internal prosthetics and other capped hospital items

A plan that looks cheap on a comparison chart may carry many of these. Check the co-payment schedule before you choose, not after a procedure is booked. Our hospital plan explained guide shows what a hospital plan does and does not pay.

These figures are illustrative, not a scheme's tariff.

Fixed co-payment. A plan charges a fixed co-payment of R1 000 on a scope. The scheme pays the approved cost above that, and you pay R1 000 unless gap cover or the scheme's rules cover it.

Percentage co-payment. For every R1 000 of an approved hospital bill, a 25% co-payment means you pay R250. The rate here is an example, not a figure from any scheme.

Sub-limit. If a plan caps a benefit and you reach that cap, every Rand above it is yours, even if your overall hospital benefit is not used up.

Always ask the scheme for the amount before the date, and ask for it in writing. Then you can decide whether to use a network hospital, choose another date after a benefit year resets, or claim on gap cover.

Gap cover is insurance that covers the difference, or part of the difference, between what a provider charges and what your medical scheme paid. From 1 April 2026 the maximum aggregate benefit for these policies is R226 881.03 per insured person per year, up from R219 845.96 in 2025, according to Treasury's annexure to the demarcation regulations. The limit is CPI-linked and changes each 1 April.

Whether a policy also pays your co-payments and how much depends on the policy, so read the schedule before you rely on it. Gap cover is not a medical scheme and does not replace one. Complaints about it go to the National Financial Ombud, not the CMS. See gap cover explained and the gap cover buying checklist.

1. Get pre-authorisation for planned admissions and procedures. See pre-authorisation explained and the pre-authorisation request letter.
2. Ask for the amount you will owe, including any co-payment, before the date.
3. Use your network or DSP where the plan requires it.
4. Check the formulary before you accept a medicine.
5. Read the sub-limits in your benefit guide for scans, dentistry and prosthetics.
6. Keep records of authorisation numbers and calls.

If a scheme charges you a co-payment on a PMB you think is protected, complain to the scheme first. If it does not resolve it, you can complain to the CMS at [email protected]. See the CMS complaints guide.