Private providers are now charging up to 5 times the basic medical aid rate your plan may pay!
In reply, healthcare plans now offer - more expensive plans - that pay at 2 or 3 times the medical aid rate.
But that is still not enough and the possible gap in claim that you could be liable for can be substantial!
Unfortunately, South Africa is a violent country and the threat of you being hospitalised is very real.
Do not think, because you have medical aid you will not face a financial threat of short-paid hospital costs - you easily can!
Do you now at what rate your scheme pays in-hospital specialists?
Medical schemes pay in-hospital costs at different rates. At the beginning of a year, all medical providers and medical schemes decide on the cost of a procedure.
This is known as the scheme (medical aid) rate. Schemes then pay at that rate.
If you use private providers, they can charge what they want - known as the private rate. This can be 5 times more expensive than the medical aid rate!
Medical aids now offer more expensive plans, that will pay up to 3 times their scheme rate, to help you with that claim shortfall.
(Generally, hospital and ward fees are charged at the scheme rate and are fully covered.)
But these rates of payment are not sufficient to prevent a potential claim shortfall.
Here are 9 common hospital procedures, including specialist and anaesthetist fees.
You can clearly see the potential payment you would have if you are on a plan that pays medical aid rates in-hospital.
|Some procedures not fully covered by medical aids.||2020 shortfalls paid by Gap Cover|
|Natural Childbirth||R 19 250|
|Caesarean Section Childbirth||R 29 645|
|Hernia Repair||R 35 622|
|Breast Cancer Surgery||R 54 158|
|Hip Replacement Surgery||R 16 877|
|Spinal Surgery||R 147 782|
|Cancer Treatment||R 120 240|
|Heart Surgery||R 165 654|
Just look at a hip replacement ... specialist and other private providers can - and do - charge R 25,300. But a medical aid pays only R 8,423 of these costs.
You have to pay R 16,877!
That's not going to help your recovery at all!
1. You can use network providers who are linked to your medical aid because, they will charge what the plan pays. So, you should never experience an in-hospital claim shortfall.
Yes, your Top Up will make good on any shortfalls or co-payments you have, up to a legislated maximum of R 173,000 per family, per year.
Please note that:
You also face financial threats of co-payments for certain procedures like:
|Gastroscopy||R 4 450|
|MRI||R 3 685|
|Admission fee||R 1 650|
|Dental procedure||R 6 820|
In order to contain costs, medical aids are increasingly imposing co-payments for treatments and procedures, like MRI, CT, ultrasounds, scopes, prosthetics and scans.
These are amounts that need to be paid to the hospital/day clinic/radiologist before undergoing certain procedures.
More expensive plans have fewer co-payments.
You pay a portion of the costs for procedures and your medical aid pays the rest. This is your co-payment.
CoPay will pay your co-payments for procedures performed in-hospital as well as some specified out-patient procedures including MRI, CT and ultrasound scans.
There are many of these plans available and they will cover most medical aid shortfall and co-payments, but this one is the most comprehensive for the price!
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Send me your questions and concerns. I'll answer them for you.
Note: Benefits are plan dependant. It is important to note that this product is specifically designed to help you meet the private tariffs charged by doctors, anaesthetists, radiologists, physiotherapists and specialist surgeons, for in-patient treatment. It does not cover the actual cost of the hospitalisation.
A standard 3 month waiting period is applicable from the date of inception to policy, and pre-existing conditions may be excluded for a minimum 12 months.
There is a total exclusion for any pre-diagnosed cancer and 12-month maternity exclusion. Terms and conditions do apply.
You owe it to yourself and your family to investigate these Top Up and Gap Cover Cover policies!
You must consult the schemes/company product brochures and rules for comprehensive benefit descriptions.
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Last update: May 6, 2021
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Medical Aid Authority Peter Pyburn.
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