Hippo Staff Writer · Published 8 May 2025 · 4 min read

How do Medical Aid co-payments work?

Medical bills have a knack for arriving at the worst possible time. Even with Medical Aid, you might still end up paying extra thanks to co-payments.

So what exactly are co-payments, why do they happen, and what can you do to avoid paying more than you need to? Let's break it down.

Hippo's quick bites:

A co-payment is the portion of a medical bill your Medical Aid doesn't cover, and you pay it yourself. It usually happens because a provider charges above the scheme rate, you've used a non-network provider, or your plan has a fixed co-payment on certain procedures.
You can often avoid or reduce co-payments by staying in-network, choosing a day clinic where possible, and pre-authorising treatment.
Gap Cover can help close the shortfall when a co-payment is unavoidable.

What is a Medical Aid co-payment?

A co-payment is the part of your medical bill you have to pay yourself, either from your medical savings (with some providers) or your own pocket, because your Medical Aid doesn't cover the full amount.

When you see the word "co-" you might think of things like co-hosting or co-pilots: words that suggest teamwork. Co-payments aren't quite so friendly.

A co-payment can also apply if the procedure you've chosen carries an upfront co-payment, or if you use a provider not contracted to your Medical Aid (a non-network provider or non-designated service provider, or DSP).

Why co-payments happen

Medical Aid plans don't always cover 100% of your healthcare costs, and co-payments are one way schemes share those costs with members.

Here's why you might end up paying a portion of the bill:

Reason	What it means
Provider charges above the scheme rate	Every Medical Aid plan pays out according to a set tariff. Many doctors, especially specialists, charge well above this rate. If your plan covers R5,000 for a procedure but your provider charges R12,000, that difference comes out of your pocket.
Using a non-network provider	Medical Aids partner with selected hospitals and providers called Designated Service Providers (DSPs), who charge within the plan's limits. Visit someone outside that network and your Medical Aid may only pay part of the bill.
Choosing a hospital over a day clinic	Medical Aids increasingly encourage members to use day hospitals or clinics for non-complex procedures, which offer the same standard of care at a lower cost. Opting for a full hospital stay for something that could've been done at a day clinic can trigger a co-payment.
Fixed co-payments on certain procedures	Some plans include fixed co-payments for procedures like MRIs, scopes or elective surgeries. These apply even when you're in-network and pre-authorised. It's a way for schemes to manage costs, and it's listed in your benefit brochure.

In-hospital vs. day clinic

Where you have a procedure done can make a big difference to what you pay.

Choosing the right setting for a procedure matters. Day procedures don't require an overnight hospital stay, so the cost of treatment, and any co-payment, is limited to that one day.

In other words, having a procedure done at a day clinic rather than a full hospital could save between 15% and 30%, depending on your plan and the procedure.

You can check for co-payments before you book

Before booking a procedure, ask your doctor for a quote. This will help you understand whether any co-payments or shortfalls are involved. Many Medical Aid schemes have online tools or helplines that let you check what's covered before you go in.

Medical savings accounts and co-payments

If your Medical Aid includes a savings account, you might be able to use it for co-payments. That's fine, but remember savings accounts are usually meant for everyday medical expenses like GP visits and prescriptions. Using your savings to cover a large co-payment could leave you short for the rest of the year.

Gap Cover can help close the shortfall

Even with Medical Aid, you might still face a large shortfall, especially if your provider charges well above the plan rate. That's where Gap Cover comes in.

For example: your surgeon charges R30,000, but your Medical Aid only pays R8,000. That leaves a gap of R22,000. With a Gap Cover plan paying 200% of the Medical Aid rate, you'd get an additional R16,000 covered, leaving you with R6,000 to pay. Cover levels vary by provider and plan, so check the specific percentage and any sub-limits before you rely on this example.

Gap Cover is designed to protect against these kinds of in-hospital surprises. It's especially useful for specialists and procedures where pricing often goes well above the Medical Aid rate.

You can compare Medical Gap Cover quotes in minutes with Hippo.

Quick tips for avoiding Medical Aid co-payments

Stick to providers in your network.
Always pre-authorise procedures when required.
Know your plan's benefits and exclusions.
Choose day clinics over full hospitals when possible.
Review your plan each year to make sure it still suits your needs.

Compare Medical Aid and Gap Cover the easy way

Co-payments are often unavoidable, but they don't have to be a surprise. Know your plan, stick to its rules, and consider Gap Cover for added peace of mind.

Need help choosing the right cover? Use Hippo.co.za to compare Medical Aid quotes and Gap Cover quotes from top South African providers. It's fast, free and commitment-free.

This article is for informational purposes only and does not constitute financial, legal, medical or insurance advice. Hippo is a comparison site helping you evaluate quotes from trusted South African insurers. Always review policy details before making changes. Quotes are risk profile dependent and subject to annual review. No fees are charged for using Hippo’s comparison service. HAS (Pty) Ltd and HCS (Pty) Ltd are authorised FSPs. Terms and conditions apply.

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