How to bridge the gaps in your medical aid

14th April 2023

Expert Advice: How to Eliminate Gaps in Your Medical Aid Coverage

– Tanya Motlafe (Head of Cornerstone Healthcare Consulting Services)

Did you know that your medical aid might not cover you in full when you are hospitalized? Every medical aid scheme option has a limit on how far it can cover your medical expenses, and certain medical events can trigger unexpected out-of-pocket expenses. That is where gap cover comes in.

This article provides insights on how Gap Cover can save you money on healthcare expenses that your medical aid cannot cover. If you’re not familiar with gap cover and would like to explore ways to save money on out-of-pocket expenses, the following is a breakdown of what you need to know to get started.

IN THIS ARTICLE

What is Gap Cover?
Understanding Gaps in Your Medical Aid Cover
Consequences of Gaps in Medical Aid Coverage
Benefits of Having Gap Cover and Is it Worth it?
Strategies for Bridging Gaps in Medical Aid Coverage
What Gap Cover Will and Won’t Cover
Gap Cover Options
There may be waiting periods before you can claim
Speak to an Expert Healthcare Consultant

1. What is Gap Cover?

Gap cover has been specially designed to cover the gap between medical aid rates and what healthcare professionals charge for in-hospital and certain out-of-hospital treatments. Medical specialists often charge higher than scheme rates, which means your medical aid will only pay a portion of the outstanding amount.

Medical Aid Gap Coverage is an additional insurance policy you can take out over and above your medical aid plan. It is designed to cover the difference between medical aid rates and what the specialists charge.

This applies to unforeseen costs and deductibles not covered by the medical schemes for in-hospital treatment. (E.g., when an in-hospital specialist charges private rates, you might have a shortfall on the account.) With medical gap cover, you won’t have to worry about excesses or co-payments, which means you’re covered for your medical expenses in the hospital.

2. Understanding Gaps in Your Medical Aid Cover

In-hospital shortfalls: When healthcare professional providers charge in excess of your medical aid rate. For example, the medical aid rate is 100% and your specialist charges 300%, which leaves you with a shortfall of 200%. In monetary value, this could set you back by thousands of Rands depending on the procedure.

Co-payments: When going for certain procedures in or out of the hospital, you might be expected to pay a certain fixed amount upfront before you receive treatment from the healthcare provider.

Deductible: A fixed amount a member must pay before the medical aid benefits cover the costs of the procedure.

Sub-limits: A limit within the amount of coverage that your medical aid provides, for a specific in-hospital event or procedure.

Casualty: When you obtain medical treatment at the emergency room (ER) or emergency unit of the hospital. This could be due to illness after hours or an accident.

3. Consequences of Gaps in Medical Aid Coverage

We’ve all heard horror stories of people being admitted to the hospital only to discover that they do not have adequate benefits on their medical aid for the specific healthcare services they need. This leaves you, as a member, vulnerable and often dissatisfied with the medical aid benefits. In private healthcare, the fees of a healthcare provider often exceed what the medical aid covers.

Becoming financially distressed as a result of medical bills may leave you unable to meet your other expenses. You may end up losing your medical aid coverage if you’re unable to pay your monthly premiums after a financially draining hospital visit. Studies have also shown that financial distress can cause hospital patients to stay sick longer as a result of the additional mental strain.

Owing large amounts of money to healthcare providers may also impact your ability to access those services in the future.

4. Benefits of having Gap Cover and Is it Worth it?

Worried that gap cover may not fit into your budget? Consider the risks of not being covered against out-of-pocket expenses that may arise if your medical aid doesn’t cover your full bill for a medical service. In the long run, the small monthly expense, which can be as little as R200 per month, is far less than what it would cost you to not be covered.

There is a wide range of affordable gap cover plans that can accommodate any budget. You want as few money worries as possible while you are dealing with healthcare challenges, and one of the best ways to protect yourself against them is to have the correct medical aid and gap cover. Make sure your gap cover complements the medical aid option in terms of what they both cover so that you don’t waste money paying for a product that can’t help you when eventualities occur.

5. Strategies for Bridging Gaps in Medical Aid Coverage

Examine the terms and conditions of your medical aid option thoroughly. What are the coverage limits, exclusions, and out-of-pocket expenses? Knowing this will help you anticipate any gaps in your coverage if you need to file a claim.

If your medical aid makes use of network providers, find out what limitations this gives you and the costs associated with out-of-network providers. You may find yourself in a situation where you have to use or may prefer to use an out-of-network specialist, which may not be covered by your medical aid.

Reach out to your medical aid scheme and ask direct questions about what gaps may occur in your coverage and address your concerns.

Now that you have done all the homework needed to make a decision, you can now begin exploring supplementary coverage options such as gap coverage insurance, health savings accounts, and other options that can fill in the gaps in coverage.

6. What Gap Cover Will and Won’t Cover

In the South African market, there are dozens of medical aid gap cover packages, each with their own scope and limitations on how far they may cover your medical aid gaps. For example, if you have an option that only pays benefits at 100% of the scheme rate, a comprehensive gap cover package will dramatically increase your cover in situations where healthcare providers may charge up to five times what your medical aid pays.

Certain out-of-hospital medical costs

It is a common misconception that you have to be admitted to a hospital in order to use your gap cover benefits.

Gap cover may cover shortfalls on many out-of-hospital benefits, such as accidental injuries, MRI scans, or CT scans. Although these procedures are mostly performed in hospitals, they are often done without the patient being admitted and therefore count as an out-of-hospital procedure.

In-hospital shortfalls

Gap cover takes care of shortfall costs for in-hospital services. This may include instances where healthcare providers charge you more than your medical aid rate.

Most gap insurance companies will pay for care at a hospital’s casualty or trauma ward if the injuries are the result of an accident or illness after hours.

Co-payments

When going for certain procedures in or out of the hospital, you might be expected to pay a certain fixed amount upfront before you receive treatment from the healthcare provider.

Deductible payments

Where a member must pay a fixed amount before the medical aid benefits cover the costs of the procedure.

Sub-limits

Limits within the amount of cover that your medical aid provides for a specific in-hospital event or procedure.

You are not covered with gap cover where medical aid does not pay for a procedure or the procedure is an exclusion unless the specific gap cover stipulates cover for exclusions.

Gap cover providers in South Africa only pay for treatments and procedures authorised by your medical aid and performed by registered healthcare professionals. Any treatment not covered by your medical aid is not covered.

Gap cover may also not cover excess fees for the following:

Allied service providers such as audiologists, chiropractors and dietitians.
Step-down facilities, including frail care
Mental health disorders
Crutches and wheelchairs
Private or Home Nursing
Any procedure subjected to a waiting period
Claims older than six months or claims which were never processed by the medical aid.

7. Gap Cover Options

Here is a table of the most popular ones with some comparative details on each.

8. There may be waiting periods before you can claim

Gap cover policies can impose a general waiting period. Some companies can make members wait 3 months before they can make a claim for gap cover unless the claim is because of an accident. Claims based on pre-existing conditions can also have a waiting period of up to 12 months.

Provider	Highest Annual Cover Limit	Premium range	Waiting Period	Benefits
Sirago	R100 000	From R395 to R791	3-month general waiting period and 10-month pre-existing conditions waiting period	● Covers up to 500% (5 times) of the medical aid tariff ● Dental ● Maternity Radiology ● Casualty ●Trauma counselling ● Accidental death and disability cover First-time cancer diagnosis
Stratum	R15 000	From R252 – R344	3-month general waiting period and 12-month pre-existing conditions waiting period	● Covers up to 500% (5 times) of the medical aid tariff ● Robotic Surgery ● Co-payments and Co-payments Charged as a Percentage ● Penalty Fee Co-payments ● Day Hospital/Clinic and/or In Room Surgical Procedures Cover ● Prescribed Minimum Benefit (PMB) Cover ● Hospital Account Shortfalls ● Sub-limit Enhancer ● Step-down ● Primary Care Benefits ● Emergency Room Cover ● Day-to-day Specialist Consultation Fee ● Preventative Care Cover ● Appliance Benefit ● Trauma Counselling
Zestlife	R182,700	From R225 per month to R710	There is no blanket waiting period at the commencement of cover.	● Up to 500% (5 times) of the medical aid tariff ● General Co-payments ● Non-network Co-payments ● MRI, PET and CT Scans in Excess of Medical Aid Sub-limit ● Casualty Facility Treatment for Injury in an Accident ● Casualty Facility Emergency Treatment ● Internal Prosthesis and Artificial Joints ● Robotic Medical Procedures

9. Speak to an Expert Healthcare Consultant

It’s best to make your decision with the help of a knowledgeable healthcare consultant who can give you accurate information and comparisons. For the best deals to cover shortfalls in your medical aid and the best expert medical advice, contact Cornerstone Healthcare Consulting Services here.

At Cornerstone Healthcare Services, we specialise in the effective management and administration of healthcare products for individuals as well as developing bespoke healthcare solutions for our corporate clients. We also provide gap cover and funeral plans to ensure that you are covered on all fronts.

As independent healthcare consultants, our advice is unbiased, and our main priority is to offer you a healthcare solution that’s cost-effective and most suitable for your family, and your employees’ needs. We believe in empowering our clients so that they can make the right medical aid choices—not only for themselves but for their families as well.

You can reach the Cornerstone Financial Services Group of companies by:

Vising our website here
Email us using info@cornerstonefsg.co.za
WhatsApp us on 068 018 0594
Calling us on (011) 794 4131

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Cornerstone Healthcare Consulting Services, Gap Cover, Healthcare, Medical Aid

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How to bridge the gaps in your medical aid