Understanding co-payments

One of the questions raised by members at the recent AMS AGM was when and why co-payments apply.

A co-payment is the portion of a medical bill that you are responsible for paying yourself. While AMS covers a wide range of healthcare services, there are situations where members may need to contribute towards the cost of treatment.

The most common reason for a co-payment is when a healthcare provider charges more than the amount covered by the Scheme. Co-payments can also apply when members choose not to use a Designated Service Provider (DSP) or network provider for certain services, or for specific procedures where Scheme rules require members to use a particular facility or treatment pathway.

Why do medical schemes apply co-payments?

Co-payments are one of the tools used by medical schemes to manage healthcare costs and ensure the long-term sustainability of benefits for all members. They also encourage the appropriate use of healthcare services and support the use of contracted providers who have agreed to provide quality healthcare at negotiated rates. AMS carefully selects its network providers to ensure members receive quality healthcare while helping to keep healthcare costs affordable.

Prescribed Minimum Benefits (PMBs)

By law, medical schemes must cover the diagnosis, treatment and care costs of PMBs in full when members use the Scheme's DSPs. If members choose to obtain PMB treatment from a provider outside the designated network without a valid reason, co-payments may apply.

We're here to help

Healthcare benefits can sometimes be complex, and the circumstances under which co-payments apply differ between benefit options and types of treatment. If you are unsure whether a co-payment may apply, contact AMS before receiving treatment. A quick enquiry can help you avoid unexpected costs and ensure that you make the most of your benefits.

How can you avoid unexpected costs?

Before receiving treatment, it is always a good idea to:

• Ask your healthcare provider whether they charge above the AMS Scheme Reimbursement Rate (SRR).
• Obtain a quotation for planned procedures.
• Use network providers where possible.
• Contact AMS if you are unsure about the level of cover available for a specific treatment.

Understanding the SRR can help you make informed healthcare decisions and avoid unexpected out-of-pocket expenses.

Independent benchmarking     Understanding the AMS Scheme Reimbursement Rate (SRR)