What is GAP cover?

More and more medical scheme members are finding they have to pay large Rand shortfalls out of their own pocket in respect of medical specialists accounts (ie surgeons, anaesthetists) for treatment while in hospital.

GAP cover covers the principal members and dependants of South African medical schemes for these out of pocket costs. The cover would be the amount of the Rand shortfall incurred in respect of a hospital procedure, by the patient as the result of the medical specialist charging above the NHRPL (national health reference price list) which is the guideline used by the medical aid industry.

The maximum GAP cover would be 3 times over and above the NHRPL. The vast majority of medical aid schemes cover hospital procedures at NHRPL or possibly slightly above this rate which puts most members at a fair degree of financial risk.

A simple example: Your anaesthetist and surgeon sent you accounts totalling R15 000. The NHRPL amount is R5 000. The shortfall, covered by your GAP cover product is R10 000.

Here is an example:

Discovery Coastal and Essential plan members are reimbursed at a level of 100% of NHRPL (historically known as the Medical Aid Rate), yet the surgeon might charge at a level of 300% of NHRPL.

Currently the member will pay 2/3rds of the specialist’s bill and the medical aid will pay 1/3rd!

Co-payment GAP – Allows a GAP user to claim back the co-payment called for by the medical aid in the case of specific procedures such as MRI & CT scans and Endoscopes.

This is particularly important for medical aid plans that have no savings attached as these co-payments can be quite large, e.g. Discovery charges a R2000 co-payment for an MRI/CT scan.

Add-On Benefits – Allows a GAP Cover user to receive R1000 per hospital admission and/or to receive R2000 for certain dentistry procedures.