MEDICAL TOP-UP COVER VS. MEDICAL GAP COVER
PREAMBLE
At Cura Administrators, we understand that many people may be confused about the differences between Medical Top-up Cover and Medical Gap Cover. According to Chapter 2 of the South African Bill of Rights, all South Africans have rights related to healthcare, including those involving healthcare providers (doctors and others) and members of medical schemes.
Healthcare providers are allowed to charge any private tariff for their services since the National Health Reference Price List (NHRPL) was declared as “price fixing” by the Competition Commission in 2006. This decision was intended to encourage competition and lower costs, but it resulted in the opposite effect, causing healthcare costs to rise significantly.
Patients have the right to choose their healthcare provider but are responsible for paying for the services received. Medical Schemes set their own tariff limits, and while some providers have agreements with these schemes for fixed fees, many do not, leading to increased costs for patients.
DIFFERENCE BETWEEN MEDICAL TOP-UP AND GAP COVER
Medical Top-up Cover, often known as Gap Cover, is a short term insurance product and is not a Medical Scheme on its own. Instead, it acts as a top-up or a supplement, enhancing certain benefits provided by your chosen Medical Scheme option. However, it cannot be used to supplement benefits that are not included in your selected Medical Scheme benefit option.
Medical Top-up Cover:
Medical Top-up Cover helps cover shortfalls where your medical scheme’s benefits fall short. For example, if your medical scheme doesn’t fully cover an internal prosthesis due to a monetary limitation in hospital, Top-up Cover fills the shortfall. It also may cover out-of-hospital expenses like radiology and pathology, depending on the insurer and and your medical plan option.
Medical Gap Cover:
Medical Gap Cover covers the difference between what your healthcare provider charges for in-hospital treatment and what your medical scheme will pay. For instance, if a procedure costs R10,000 but your scheme only pays R5,000, Gap cover takes care of the remaining R5,000. It’s often included as part of a broader Top-up Cover package.
THE NECESSITY OF MEDICAL TOP-UP COVER (“GAP COVER”)
The rising tariffs charged by healthcare providers created a gap between what Medical Schemes pay and what providers charge, making healthcare unaffordable for many. The need for a short-term policy, such as Medical Top-up cover (Gap Cover), became essential. To protect themselves against high claims of “medical negligence”, “over–servicing,” and an escalation in tests and procedures to minimise medico-legal hazards, healthcare providers subsequently increased their tariffs.
Medical schemes could not absorb the extra costs of tests and procedures like MRIs, CT Scans, and Blood Tests. Co-payments were introduced by medical schemes to minimise “over–servicing.” These co-payments became the responsibility of the scheme members / patients.
EXPANSION OF “GAP COVER” TO TOP-UP COVER
As the gap between medical schemes payments and provider charges increased, medical scheme members needed additional coverage, leading to the development of Medical Top-up Cover. Some insurers remained with the traditional Gap Cover only, which is now one of the benefits of comprehensive Medical Top-up Cover, at a lower premium. Choosing a plan based on price alone can lead to significant out-of-pocket expenses for items like internal prostheses, radiology, pathology, and biological cancer drugs.
According to the Medical Schemes Act (Act 131 of 1998, as amended), medical schemes must pay for Prescribed Minimum Benefits (PMB) at cost if the member uses a Designated Service Provider (DSP). However, members may not always be willing to accept DSP conditions due to potential inconveniences like traveling long distances or changing healthcare providers. If members do not use a DSP, the medical scheme will only pay at the scheme tariff, and patients may face additional costs, including penalties.
PURCHASING THE CORRECT PRODUCT
When choosing a product, several factors should be considered beyond price. Ask yourself:
WHY DO I NEED COMPREHENSIVE MEDICAL TOP-UP COVER AND NOT ONLY GAP COVER?
Like medical scheme membership, it’s impossible to predict the future. Whether you may face cancer, serious illnesses, accidents, hip and knee replacements, back operations, or cardiac conditions; having comprehensive Medical Top-up Cover provides peace of mind. It protects you against large out-of-pocket expenses that may arise from unexpected incidents, offering more than just basic Gap Cover where your medical scheme benefits are depleted depending on the Medical Top-up product / option chosen.
YOUR OBLIGATION TOWARDS YOUR HEALTHCARE PROVIDER
You are always responsible for paying your healthcare provider. Your medical scheme acts as insurance, covering up to a certain amount for day-to-day benefits and generally offering unlimited hospitalisation at medical scheme tariffs. However, when healthcare providers charge above these tariffs or when expensive procedure limits are exhausted, the additional cost falls on you. Medical Top-up Cover helps cover these shortfalls. It’s not necessary to disclose your Medical Top-up Cover to your healthcare provider as this could lead to increased premiums if insurers experience losses.
CONCLUSION
Healthcare providers have the right to charge ethical fees for their services, and you have the right to choose your provider. You also have the right to protect yourself financially to ensure coverage for expensive procedures through a Medical Top-up cover policy. This protection is for you and not for providers to inflate their tariffs, should they know you have this cover.
ENSURE YOUR FINANCIAL PROTECTION BY CHOOSING THE RIGHT COVER
Contact your Cura Medical Top-up (Gap Cover) Advisor for guidance or reach out to Cura Administrators on 010 021 0260 or email mail@curaadmin.co.za
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Gareth Stokes, FAnews Online Editor