MedXpert
Making sense of...
Gap Cover
GAP COVER PROVIDES PROTECTION FOR UNEXPECTED EXPENSES RESULTING FROM SPECIALISTS CHARGING MORE FOR IN-HOSPITAL PROCEDURES THAN WHAT
YOUR MEDICAL SCHEME COVERS.
Gap Cover has become a necessity
- The number of upfront co-payments introduced by medical schemes is going to stay and, many schemes increase these amounts annually.
- Due to high medical inflation, the fees charged by medical specialists for planned in-hospital procedures, are much higher than the rate at which medical schemes settle claims.
When will a medical scheme member be exposed to upfront out-of-pocket payments?
Upfront co-payments can be in the form of a fixed amount or a percentage of the cost.
These fixed co-payments are specified in your medical scheme’s rules to be paid at the point of service before medical treatment. This is typically applied to:
- MRI and CT scans
- Endoscopic procedures for example a laparoscopy or gastroscopy
- Back operations
- Cancer treatment once limit is exceeded – percentage co-payment, generally 20%
Penalty co-payments are applied when consumers fail to get pre-authorisation or use non-DSP hospitals for planned procedures.
100% medical scheme cover does not mean specialist bills are paid in full.
Medical Schemes pay for in-hospital procedures at 100%, 150%, and in the case of a few more comprehensive benefit options up to 200% of the medical scheme rate (MSR).
These rates are determined by each medical scheme and might also differ per benefit option on the same scheme.
The rate charged by your treating specialist can be much higher than the medical scheme rate.
An affordable solution
Gap cover offers protection against these unexpected shortfalls and co-payments at affordable monthly premiums.
When confronted with a co-payment or shortfall on an in-hospital medical bill, you submit a claim to your Gap Cover product provider.
The Gap Cover provider will pay the amount into your bank account as per their product policy wording.
