Depending on what Medical Scheme and Option you are on, your scheme will cover the bill for the hospital and specialist/s at your scheme’s rate, i.e. at 100% rate. As we learnt in ‘100% of the Medical Aid Rate – What Does It Mean?’ (read it here), a Medical Scheme may only cover you at 100% rate, but often specialists charge more than the 100%, such as 400% or even more. It is for this 400% which Gap Cover is used and “covers the gap” between the 100%* your Medical Scheme pays and the frequently high additional costs which you are liable for.
Gap Covers have evolved and providers also pay for commonly charged co-payments. This is an amount owing upfront for hospital admission and specialist procedures. These payments are paid upfront by the Medical Scheme member and the invoice and statement are supplied to your Gap Cover and you are reimbursed. Submission to your Gap Cover provider can vary in procedure, such as filling out additional claim forms and supplying statements, hence we recommend using Quattro Med as they fill out the paperwork and do the administration required.
As we uncovered in ‘100% of Medical Aid Rate – What Does It Mean?’ (read it here), a Medical Scheme payment is often lower than what a specialist charges, even if your Medical Scheme covers you at 100%. As unfortunate as it sounds, it is common practice for specialists to charge more than most Medical Scheme rates which means you are personally responsible for the entire shortfall.* Most specialists charge between 300% and 600% above the Medical Aid Rate.
The short answer – no. Gap Cover and medical aid work together, as you recall, as it covers the gap which you Medical Scheme does not cover. If Bob chose to sign up for Gap Cover with a provider over the phone but did not have medical aid, when it came time to claiming or getting approval for his hospital admission, his claim would have been rejected as the Gap Cover had no ‘gap’ to cover, because there is no Medical Scheme covering a portion and thus there is no shortfall for Gap Cover to cover.
*Please note that Gap Cover and Medical Scheme benefits are subject to your selected option and its applicable rules. Benefits can vary as well as the percentage at which you are covered.