What is Medical Gap Cover?
Medical aids reimburse doctors and specialists at between 100% to 300% of medical aid rates, but the reality is that many medical practitioners charge well in excess of these rates, which could result in a gap between the actual cost of the procedure and the amount that the medical aid will pay. As a medical aid member you are then liable for the difference.
Medical aids may also impose upfront co-payments for in- and out-of-hospital procedures such as scopes, scans and deductibles. Depending on your medical aid option, these co-payments are either payable from your Medical Savings Account, or as an out-of-pocket expense.
What are my Plan choices?
We have packaged 4 benefit combinations that we believe are the most popular with our clients.
Tariff Gap @ R150 pfpm (per family per month)
(Health Rate Enhancer + Non-Insurance Product*)
(Also available to Seniors between the ages of 71 and 80 years of age as Tariff Gap Seniors for R205 pfpm.)
Tariff Gap Plus @ R170 pfpm.
(Health Rate Enhancer + Self-payment Protector + Non-Insurance Product*)
(Also available to Seniors between the ages of 71 and 80 years of age as Tariff Gap Plus Seniors for R245 pfpm.)
Tariff Gap Cancer @ R200 pfpm.
(Health Rate Enhancer + Cancer Treatment Shield + Non-Insurance Product*)
Tariff Gap Supreme @ R240 pfpm.
(Health Rate Enhancer + Self-payment Protector + Cancer Treatment Shield + Hospital Sub-Limits Extender + Non-Insurance Product*)
*All our plans include access to a Non-Insurance Product which consists of two Helplines, i.e. the “Call a Nurse/Doctor” Helpline (where you will receive personalised attention from a registered nurse or doctor) and the HIV Trauma Helpline (to assist if an individual is exposed to the HIV Virus through rape, assault, needle stick injuries, motor vehicle accidents and other exposures).
Health Rate Enhancer (Tariff Gap) eliminates the shortfall between the actual cost of Specialist’s Bills for In-Hospital procedures and the re-imbursement rate applied by your medical aid up to a maximum of 500% of Tariff.
The Self-payment Protector benefit is equal to the charges levied by your Medical Aid in the form of any co-payments or deductibles, limited to R30 000 in aggregate per annum per insured, and R50 000 in aggregate per annum per family.
The Cancer Treatment Shield benefit is a benefit that will cover any shortfalls relating to limitations imposed by your Medical Aid for the treatment of cancer. Maximum of R200 000 in aggregate per annum per family.
The Hospital Sub-Limits Extender covers any sub-limits imposed by your Medical Aid for in-hospital admissions up to a maximum of R30 000 in aggregate per annum per family.