Benefits & claims
Co-payments and sub-limits explained
By Naledi Mokoena · 5 min read · Updated 24 June 2026
A co-payment is a fixed amount or percentage you pay yourself towards a specific procedure, while a sub-limit is a rand cap the plan puts on a particular benefit. Both are ways schemes control costs, and both can leave you with a bill you did not expect if you do not check beforehand.
Co-payments and sub-limits are not the same as a deductible on PMBs or a waiting period. They apply to defined procedures and benefit categories. This guide shows where they typically appear and how to plan around them.
Co-payments: what you pay
A co-payment is your share of a cost. It can be:
- A fixed rand amount on a specific procedure, like a scope or a scan
- A percentage of the cost, often where you use a non-network hospital or provider
Co-payments are most common on planned (elective) procedures. The scheme tells you upfront when one applies, so always get pre-authorisation and ask about co-payments before booking.
Sub-limits: the cap inside a benefit
A sub-limit is a maximum the plan will pay for a particular category, even if your overall benefit still has money in it. For example, a plan might cover hospitalisation broadly but cap internal prosthetics, MRI and CT scans, or specific dentistry at a set amount per year. Once the sub-limit is reached, you pay the rest.
Common procedures with co-payments
Co-payments and sub-limits often apply to:
- Scopes such as gastroscopy and colonoscopy
- MRI and CT scans
- Certain joint and spinal surgeries
- Dental work under anaesthetic
- Using a hospital outside the plan's network
These vary by scheme and plan, so check your specific benefit guide.
How to avoid surprise bills
Three habits save money:
- Get pre-authorisation for any planned hospital admission or procedure.
- Ask the scheme what you will owe before the date, including any co-payment.
- Use network hospitals and DSPs where your plan requires it, to avoid the non-network percentage co-payment.
Gap cover can also pay many co-payments - see gap cover explained.
Frequently asked questions
What is a co-payment on medical aid?
A co-payment is the portion of a procedure you pay yourself, either a fixed rand amount or a percentage. It is common on planned procedures and when you use a non-network provider.
What is a sub-limit?
A sub-limit is a rand cap the plan places on a specific benefit, such as scans or internal prosthetics. Once you reach the sub-limit, you pay any further cost in that category yourself.
Can I avoid co-payments?
Often yes, by using network hospitals and DSPs, getting pre-authorisation, and choosing the scheme's preferred providers. Gap cover can also pay many co-payments on in-hospital procedures.
Do PMBs have co-payments?
PMB care must be paid in full if you use the designated service provider. A co-payment on a PMB usually means you used a non-DSP without a valid reason. Using the DSP avoids it.
Why was I charged a percentage at the hospital?
Most likely you used a hospital outside your plan's network, which triggers a percentage co-payment. Using a network hospital where your plan requires it avoids this charge.
Does gap cover pay co-payments?
Many gap cover policies pay co-payments and deductibles on in-hospital procedures, up to their limits. Check the specific policy, since cover for co-payments varies between insurers.
