Bridging
the Gap
Gap & co-payment cover is an insurance product that boosts your existing medical scheme cover, providing benefits for medical scheme shortfalls and extra medical expenses for services rendered in hospital, and some selected out of hospital treatments.
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Medical shortfall cover that can make all the difference.
What is Gap Cover?
As a medical scheme member, you have cover for a defined set of benefits according to your specific option. The scope of your healthcare coverage varies from plan to plan and from scheme to scheme.
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Generally, the higher the cost of your medical scheme option, the more extensive your benefits will be. Higher cover limits for healthcare services rendered in- or out-of-hospital, a larger savings account allocation, and cover for a wider range of procedures and treatments are all examples of more comprehensive benefits.
How much do medical schemes cover?
Medical Scheme Rates are the tariffs or rate structures that medical schemes use to pay your claims (MSR). This is the set rate (or tariff) that your scheme option covers for procedures and treatments, both in-hospital and outpatient services, as well as routine medical care.
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Most medical plan options offer cover at 100% of the Medical Scheme Rate. In fact, some more expensive options might offer up to 200% or even 300% of the Medical Scheme Rate.
Does 100% medical scheme rate mean that 100% of my medical bill is paid?
Unfortunately, that is not always the case.
In South Africa, the cost of professional healthcare services is not regulated. This means that your general practitioner (GP), dentist, optometrist, specialist, and even hospitals may charge whatever fees they choose, so long as the fees are deemed to provide "fair value" to the patient.
This means that a specialist may charge, for instance, five times the medical scheme rate, or 500% (or even more, based on their interpretation of "fair value"). Thus, if your plan covers up to 100% of the medical scheme rate, but the specialist charge is 500% of the medical scheme rate, you will be responsible for 400% of the bill.
This difference is called a medical shortfall, also referred to as a GAP.
You have to cover the medical shortfall from your own pocket.
Unless your private healthcare provider remains within Medical Scheme Rate or is contracted on your scheme's network, the most expensive, all-inclusive plans might not cover your healthcare bills in full. You could be left with a hefty shortfall if the healthcare provider charges four or five times the Medical Scheme Rate.
This is where gap cover steps in.
Gap insurance is a type of medical insurance that pays the difference between what your medical scheme option covers and what your healthcare provider charges for your treatment.
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Gap cover = less, or even zero, out-of-pocket expenses.
Can you have gap cover without medical aid?
No, gap cover is an add-on to your existing medical scheme cover and must be used together.
You can, however, combine any medical scheme with any gap cover - it does not have to be from the same provider. So in other words, you can be a member of any medical scheme in South Africa, for example Discovery, Momentum, Bonitas or Fedhealth and have Agility Gap Cover as a value-added addition to boost your personal healthcare solution and ensure you’re protected against medical shortfalls.
Shortfalls vs co-payments
It is important to know that there is a difference between what we just discussed as being a shortfall, and what a co-payment is.
Shortfalls usually relate to in-hospital treatments and the difference between the professional fee charged by your provider and the Medical Scheme Rate, depending on which gap cover you purchase.
In contrast, co-payments are usually set by your medical scheme, which is a payment you are required to make for a procedure done in hospital, in the doctor’s rooms, or for specialised radiology like MRI and CT scans.
Again, this will have to be out of pocket.
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Often, gap cover does not pay for co-payments, but the Agility Combined range does.
Gap and co-payment cover will take care of your unforeseen medical expenses.
So, to sum up:
Gap and co-payment coverage is purchased as a supplement to your existing medical scheme cover. Depending on the option you select, it will cover medical shortfalls as well as co-payments.
Why we believe in our Agility Gap & Co-pay products.
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We have some of the most affordable gap & co-pay products in South Africa, which include some of the most comprehensive cover.
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We have a wide range of products to suit every specific need, from only shortfall cover to our combined range that pays for shortfalls and co-payments (we recommend these options as they’re better value for money).
We provide a variety of options to help you bridge the financial gap. If you're ready to take the next step to reduce your financial risk and protect your family's health, take a look at our products: Click HERE.
Agility Gap & CoPay is a division of Agility Insurance Administrators (PTY) Ltd. Products are underwritten by GENRIC Insurance Company Ltd (FSP 43638) GENRIC Insurance Company Ltd is an Authorised Financial Service Provider. Agility Gap & CoPay is a division of Agility Insurance.
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