2026 Rules Active
2026 Strategy Validated
Evolve Maternity: Co-Pay Exception
Evolve Maternity Path (Co-pay exception aware) strategy verified
Covering 0 family members
2026 rates applied
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Actuarial Strategy Reference
This strategy is generated based on the 2026 Council for Medical Schemes (CMS) registered rules and actuarial pricing matrices.
VERIFIED: 2025-12-20 | SOURCE: SCHEME_BENEFIT_GUIDE_2026
Similar Situations
Key Terms Explained
Key Terms for this Strategy
- Elective Procedure Co-payment
- A mandatory upfront fee you must pay to the hospital for specific scheduled surgeries that are not emergencies. [Source: Council for Medical Schemes Official Benefit Rules]
- PMB (Prescribed Minimum Benefits)
- By law, this plan must cover the costs of 27 specific chronic conditions and emergency treatments. [Source: Council for Medical Schemes Official Benefit Rules]
Common Questions
Can I use a private doctor for my chronic diabetes or blood pressure? [Evolve Maternity Path (Co-pay exception aware)]
No. On the Evolve Option, chronic benefits are available from State facilities only. You must use State doctors, scripts, and medication for the 26 covered conditions. Strategy reference: ion-2026.
Do I have to pay every time I go to the hospital? [Evolve Maternity Path (Co-pay exception aware)]
Yes, there is a standard co-payment of R2,000 per authorisation for all hospital admissions, unless it is for a motor vehicle accident, maternity, or emergency. Strategy reference: ion-2026.
What if I need a hip or knee replacement? [Evolve Maternity Path (Co-pay exception aware)]
Joint replacements (hip and knee) are limited to Prescribed Minimum Benefits (PMB) at State facilities only. There is no private hospital benefit for these surgeries. Strategy reference: ion-2026.
Is there a limit on cancer treatment? [Evolve Maternity Path (Co-pay exception aware)]
Yes, oncology is covered up to R200,000 per beneficiary per year. Thereafter, a 20% co-payment applies. You must use the Evolve Network of Oncologists. Strategy reference: ion-2026.
Do I get day-to-day GP visits? [Evolve Maternity Path (Co-pay exception aware)]
You get 2 virtual GP consultations via the Hello Doctor app. For physical GP visits, there is no benefit unless you have funds in your optional HealthSaver account. Strategy reference: ion-2026.
Are MRI and CT scans covered? [Evolve Maternity Path (Co-pay exception aware)]
Yes, there is no annual limit for scans in or out of hospital, but a co-payment of R3,850 applies per scan. Strategy reference: ion-2026.
What happens if I need a gastroscopy? [Evolve Maternity Path (Co-pay exception aware)]
You will pay a R2,000 co-payment if done in a day hospital. If done in an acute hospital, the co-payment increases to R7,500 (R2,000 standard + R5,500 penalty). Strategy reference: ion-2026.
Is dentistry covered? [Evolve Maternity Path (Co-pay exception aware)]
There is a preventative dental care benefit of R500 per beneficiary per year. Major dentistry is not covered. Strategy reference: ion-2026.