Considering taking out gap cover? Here’s what you need to know

Healthcare in South Africa is in a state of flux due to a shifting regulatory landscape compounded with the current economic challenges the country is facing. This environment can be complex and challenging to navigate for most people, even if they have already purchased health cover products. Many medical aid options have network restrictions with upfront co-payments, limiting choice and access to get the appropriate level of care from certain hospitals or specialists. This can leave households out of pocket and create immense pressure and worry for families who might have a loved one who needs immediate access to healthcare not covered fully by their medical aid.

Circumstances that require the use of medical aid are rarely pleasant. These situations can be stressful and even traumatic, depending on the severity of the condition and the treatment required. Compound this with unexpected costs that may not be covered by medical aid and an already challenging situation takes a turn for the worse. This is where gap cover acts like a shock absorber for shortfall costs that are charged by healthcare providers but not fully covered by medical aid or for unexpected co-payments.

Anyone requiring healthcare that is not covered fully by their medical aid might feel that the treatment options available to them are limited or even inaccessible if they do not have the finance available to pay for these additional costs.

The limits applied by medical schemes vary depending on the type of plan you may have – however any extra costs or shortfall beyond these limits can be covered by taking out gap cover.

“Life can be unpredictable, but healthcare costs don’t have to be,” explains Teshlin Akaloo, managing director of NetcarePlus. “Given the current climate of uncertainty and unemployment, there has never been a greater need for new, affordable ways to access private healthcare to ensure that taking care of medical needs does not impact household budgets with unexpected out-of-pocket expenses.”

Here are some things to consider when looking at taking out gap cover:

Understand what your potential gap cover will accommodate

Understand your needs first to ascertain what type of gap cover will best suit you and your family and ensure that you consider what healthcare facilities and treatment options are available and accessible from the cover before you decide.

Gap cover products should be carefully considered – there are various gap cover products in South Africa that offer a wide range of benefits that vary according to your chosen product provider. If you belong to a medical aid option that only pays benefits at 100% of the scheme rate, for example, a comprehensive gap cover product will significantly boost your cover in an instance where healthcare providers may charge a rate of up to five times more than what your medical aid pays.

Value for money

The services offered by medical schemes and gap cover providers need to be carefully evaluated to ensure they are beneficial to you and your family. Maximise value by ensuring that your gap cover matches the potential medical costs without wasting money on unwanted features and services.

“At NetcarePlus, we offer a wide range of options that are tailored for people on different medical aid options. These include GamCare, GapCare300+, and GapCare500+, a comprehensive selection of gap cover for the shortfall in medical expenses to members on any medical aid. In addition to the typical benefits offered by gap cover providers, NetcarePlus GapCare includes cover for emergency department costs that are not limited to accidents, additional cover for day-to-day expenses when medical aid limits have been reached or savings have been depleted, including coverage options for high-risk pregnancies and other maternity-related benefits,” continues Akaloo.

Lastly, upfront co-payments and access to hospitals that may not be on your medical aid’s network also need to be considered when thinking about taking out gap cover.

“Many medical schemes have network restrictions limiting access to certain hospitals or specialists and this can leave households out of pocket. Shortfalls covered by NetcarePlus GapCare are for any hospital, and not restricted to the use of Netcare hospitals only”, Akaloo adds.

Does your gap cover complement your medical plan?

It is important to make sure that your gap cover complements your medical aid, as gap cover can only cover you for what your existing medical plan covers – gap cover is intended to augment your medical aid. It is also important to consider cover for sub-limits, co-payments, and deductibles. Many medical aid options apply upfront co-payments when using out-of-network hospitals, limiting choice and options to quality healthcare.

“Creative options are needed now more than ever to answer to the complexities of the South African healthcare landscape for the benefit of more South Africans,” concludes Akaloo.