How NetcarePlus GapCare extends cover for day-to-day benefits

An innovative medical insurance solution South Africans have been waiting for

Out-of-pocket expenditure for medical scheme members has skyrocketed over the years. The Council for Medical Schemes reported an increase from R19bn in 2013 to R36.7bn in 2021. Fortunately for those on medical aid, an effective way to manage extra medical costs or shortfalls is by taking out gap cover. While gap cover is not a substitute for medical aid, by having this cover in place, members can have more peace of mind knowing that they won't be left with medical bills that they wouldn’t necessarily afford to pay.

Although outpatient shortfalls account for nearly half of out-of-pocket expenditure, most gap cover products focus on in-patient shortfalls. NetcarePlus GapCare addresses this market gap, providing up to R20 000 per insured per annum for outpatient costs.

NetcarePlus has made this possible with a carefully thought-through benefit design to balance members’ needs and potential abuse. The following benefits will be covered on an outpatient basis once an insured’s savings account has run out or if the insured has depleted their day-to-day benefit sub-limit:

• The cost of specialist consultations that are deemed necessary by a general practitioner
• Outpatient basic dentistry
• Fillings and extractions
• Outpatient specialised dentistry
• Root canals, pulp removal, and specialised X-rays
• Reconstructive dentistry due to an accident, trauma event or oral cancer
• Specialised radiology or pathology that is deemed necessary by a patient’s general practitioner or specialist for treatment and diagnosis purposes

This day-to-day benefit is not available to medical scheme members who belong to a hospital plan only.Day-to-day costs beyond medical scheme limits benefit: IN ACTION

For a more tangible understanding, let's explore a practical example featuring one of the popular medical schemes that NetcarePlus GapCare frequently supplements.

The following figure provides an illustrative overview of the annual medical savings account for all applicable benefit options under this medical scheme, for a main member in the 2023 calendar year. More importantly, it demonstrates how the NetcarePlus GapCare 500+ can bolster the medical savings account with an additional R20 000 for a main member.

Therefore, with the GapCare 500+ product, members on a medical scheme option that includes a medical savings account can potentially double their day-to-day benefits (depending on the specific benefit option) – an impressive enhancement that comes at a minimal cost.

Next, let's examine the cost versus benefit balance, using an entry-level scheme option as our case study. In 2023, the monthly contribution for a main member is R3 220. Adding a typical GapCare 500+ premium of R280 (note that this premium can differ for employer groups), the total monthly cost rises to R3 500 – a mere 9% increase.

Here’s the real magic: This member would see their medical savings account leap from R7 575 to a staggering R27 575. That's a monumental benefit increase of 264%.

Therefore, our gap cover supplements the entry-level scheme option with NetcarePlus GapCare 500+, and generates a value-for-money increase of 235% for the member. It's a win-win situation – members achieve increased coverage while spending only a fraction more.

NetcarePlus GapCare isn't an average gap cover product. Subscribing to NetcarePlus GapCare allows usage of any Netcare hospital, despite any restrictions imposed by a medical scheme.

Beyond the industry standard offerings, NetcarePlus GapCare also provides shortfall cover for:

• In and out-of-hospital specialist shortfalls: This benefit covers the difference between the amount charged by a specialist and the amount covered by the insured’s medical scheme, for consults and medical treatment provided out of hospital.
• Out-of-network hospital co-payments: If the insured chooses to use a hospital that is outside the prescribed network, the scheme will charge the insured a co-payment. This benefit covers the co-payment that has been applied by the medical scheme.
• Charges above sub-limits: The medical scheme may impose sub-limits for certain procedures or prosthesis, or limit the number of days that a patient may be treated in a mental health institution, rehabilitation, step down or sub-acute facility. This benefit covers the additional cost incurred by the insured, once the sub-limit has been reached for a procedure or prosthesis.
• Emergency medical treatment in an emergency department: This benefit covers the costs that are incurred in the emergency department of a hospital when an insured person requires emergency medical treatment.
• Maternity costs: This benefit covers the private ward fee, in and out-of-hospital shortfalls, certain maternal benefits on an outpatient basis, once an insured’s savings account has run out or if the insured has depleted their day-to-day benefit sub-limit. Certain costs will be covered if the insured chooses to give birth at a hospital within the NetcarePlus network.
• Emergency department extender: Covers the costs that are incurred in the emergency department of a hospital when an insured person requires emergency medical treatment.

Ready to leverage this remarkable value? Reach out to your dedicated NetcarePlus Business Development Manager to arrange a quote, and help your clients maximise the value for money they derive on their journey of bridging the healthcare gap.