Making sure your family has the best possible medical cover is a top priority, but achieving that goal can be challenging. “Medical plans are complex, and there are many products, including gap cover to ensure high costs don’t derail your finances,” says Michael Emery, Marketing Executive at Ambledown Financial Services. “Working out which plan is best for you, and what the terms actually mean, is time-consuming, and mistakes could have dire consequences. Building a relationship with a reputable advisor remains the best way of ensuring you understand what the options are, and what’s best for you.”
Here are some of the most common issues members face – and what leading advisors advise:
Can I reduce costs of medical cover? Charleen Rix, Head of Sasfin Health Consulting, emphasizes that the key factor is to understand your usage patterns and compare them with what your plan offers.
“Only when you understand what medical cover you need can you make an informed decision about whether a different plan would be more suitable and what gap cover product should be added,” she says. “There’s always a risk that lowering one’s medical cover could make one vulnerable to unexpected medical expenses that have to be covered by the member.”
What are the implications of cancelling or downgrading my medical cover? Westley van Rooijen, Head of Healthcare at Austen Morris Associates, says that cancelling medical is a radical decision. “It will expose you to more risk in the event that you do contract a serious medical condition – how are you going to mitigate that risk?” he asks. “Cancellation could also complicate things if you later decide to rejoin a medical scheme. Many people think that they can cancel medical cover and retain their gap cover, which is impossible. Consulting with a reputable advisor is essential.”
Similarly, members under financial pressure often consider downgrading their medical cover. Again, says Van Rooijen, expert advice is necessary. An advisor can help find a medical scheme with a better financial profile and also help source a gap cover that would help cover shortfalls.
How can I get the best value from my current plan and cover? Rix says that one of the best ways of maximising value from one’s current medical scheme is to use the suppliers on its network. “These approved suppliers’ rates will be fully covered by the medical scheme, whereas out-of-network suppliers might charge higher rates which would not be fully covered. In the latter case, gap cover would be advisable,” she says.
Will gap cover finance all in-hospital shortfalls? Van Rooijen says that gap cover will typically cover the shortfalls between what the medical scheme pays and what hospital procedures cost for authorised procedures where the specialist/s charges above the medical scheme tariff. “Make sure you have provision for the medication needed on release from the hospital if it is not fully covered by your medical plan,” he adds.
Could I enrol my parents on my gap cover, and does it cover my adult children if they are on my medical aid? Most gap cover plans don’t cover extended family, except for adult children who are full time students or disabled, says Rix. A separate gap cover policy would need to be taken out, even in the case of adult children who are on the same medical scheme. Be sure to consider the policy terms and conditions, and speak to an accredited advisor.
Does gap cover pay for everything that the medical scheme does not? “It’s a common misconception that gap cover can be used to pay for medical expenses when your medical savings account is exhausted or when you are in a self-payment gap,” says Rix. “In fact, gap cover complements the medical scheme, coming into play when there is a shortfall (or gap) between what the medical scheme pays and what is charged. In these cases, the medical scheme is not paying, so gap cover does not apply.”
Similarly, she adds, if a particular medical procedure is not covered by the member’s medical scheme, gap cover would not apply. It is important to note that gap cover is not a medical scheme, nor is it a replacement for a medical scheme therefore it may not act as a medical scheme.
Emery says one cannot overestimate the value an expert advisor can add. “Medical schemes and complementary products like gap cover and medical insurance are carefully designed for specific profiles, and care needs to be taken to sign up to one that is suitable to one’s life stage,” he says. “In every instance, members need to understand fully what is and what is not covered by a medical scheme or gap cover policy, and an advisor can help ensure you make the right choices. Consult with a reputable advisor to find the best medical cover tailored to your needs and to ensure you and your family are fully protected,” concludes Emery.
Ambledown Financial Services is authorised Financial Services Provider No.10287. Gap Cover is not a medical scheme and the cover is not the same as that of a medical scheme. Gap Cover is not a substitute for medical scheme membership.
