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Understanding the role of Gap Cover in Co-payments and deductibles

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Having medical aid comes with peace of mind and ensures you have access to quality private healthcare. But there are terms and conditions that come with your cover. If you do not understand these conditions, you might feel you are not getting your money’s worth.
This article will tackle one of the terms and conditions to your coverage- Co-payments and deductibles. You will learn what they are and how you can get ahead of the expenses they come with.
Let’s look at the difference between a co-payment and a deductible before we dive deeper into co-payment.

What are co-payments and deductibles?

A co-payment is a fixed amount you pay each time you get a particular type of healthcare service.
Let’s say your medical aid covers a hospital procedure like surgery which costs R5000. The co-payment you are expected to pay is R1500 upfront, to the hospital, with your medical aid scheme paying for the rest of the bill. Co-payments do not change for that particular service no matter what the healthcare provider charges:
• Paid by Insurance= R3500
• Paid by Policyholder= R1500

With healthcare costs increasing each year, co-payments are getting larger and more common with many medical aid providers. This means that you may be subjected to paying large amounts out-of-pocket. The more the healthcare provider fee, the higher the co-payment.

A deductible is the amount you must pay toward the cost of your medical bills before your insurance company begins to cover your expenses.
Deductibles can range from hundreds to thousands of Rands depending on your insurance plan and they normally renew every year.
If your medical aid plan has a deductible, you will have to pay for some services yourself. Once you have paid the full deductible, your medical aid scheme will either share or fully cover the costs of your care.

How deductibles work

Here is how meeting your deductible works:
1. Submit claim
2. Pay from your pocket
3. Meet deductible
4. Insurance pays out

Good thing to know about these conditions is that there is a way to get ahead of them and avoid paying out-of-pocket for your medical expenses. That solution is called Gap cover.

The role of gap cover in co-payments and deductibles

Gap cover fills the gaps left by your medical aid by paying for healthcare services your medical aid won’t reach. Gap cover complements your medical aid plan and therefore doesn’t extend to services outside of your benefits.
How does it then work on co-payments and deductibles? Although there are limits, it takes care of the co-payments and deductibles you would be expected to pay from your own pocket.
Co-payments on medical aid are common depending on the plan you are on. Remember, they require you to pay a certain amount of money for healthcare services. With gap cover, you can claim it back.
The same applies with deductibles, you will not need to pay out of pocket because gap cover will cover it for you.

Focus on good health, not covering unexpected medical bills

Co-payments and deductibles have forced so many medical aid members to focus more on medical bills instead of recovery. These expenses can rack up quickly, making it difficult for anyone to keep up. With Gap Cover, these unexpected bills can be taken of. It might feel like you’re not getting your money’s worth, but having Gap Cover transforms medical aid into something priceless.


Frequently Asked Questions

1. What types of medical expenses does Gap Cover typically address?
Gap Cover addresses various expenses, including tariff shortfalls, sub-limits for internal prosthetics, dental reconstruction for accidental injury, and oncology co-payments and standard co-payments and deductibles

2. Does Gap cover cover copayments?
Depending on which gap option you have, your gap cover will reimburse you for the penalty co-payment that you have to pay upfront for voluntarily making use of non-designated hospital service provider, subject to the terms of your cover.

3. What is the difference between a deductible and out-of-pocket?
Essentially, a deductible is the cost a member pays for health care before their insurance starts covering any expenses, whereas an out-of-pocket maximum is the amount a policyholder must spend on eligible healthcare expenses through copays, coinsurance, or deductibles before their insurance starts covering all.

Not all Gap Cover plans are the same and benefits as well as limitations may vary. Descriptions of benefits given are meant to be for general educational purposes only and you must ensure that you seek the advice of a broker to ensure any product choice you make suits your individual needs.

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