Stratum Gap Cover
Stratum is SACA’s gap cover and co-payment insurance cover for its members. SACA funds the full monthly Stratum premium for members and their dependents.
Click here to download the Stratum brochure
Stratum’s gap cover policy offers solutions for in-hospital shortfalls and co-payments experienced by SACA’s members on their medical aid, allowing its members to access private, and high-quality healthcare and simultaneously be adequately insured.
Co-payment is a fixed, upfront fee that is payable on certain procedures. These usually apply to defined surgical procedures, basic in-patient dentistry and diagnostic services such as MRI/CT/PET scans and scopes.
There is normally a shortfall between what your medical aid will cover and the actual cost of your procedure or treatment as service providers can charge above the medical aid rate. Without gap cover, this shortfall will be at your own expense. Being a professional sportsman/ women you want the security of being able to see the best practitioners without having to be concerned about the shortfall incurred.
Players must settle the medical account and then claim back from Stratum by following the steps below:
- Download and fully complete the client claim form
- Get a detailed hospital account (tax invoice) from the provider
- Ensure the provider account has the correct ICD 10 codes outlined
- Get a detailed medical aid statement
- Submit the above as well as any proof of payment to Tessa at firstname.lastname@example.org
Click here for a Basic Claims Guide which will provide you with further information.
Co-payment is a fixed, upfront fee that is payable on certain procedures. These usually apply to defined surgical procedures, hospital admission, basic in-patient dentistry and diagnostic services such as MRI/CT/PET scans and scopes.
Doctors or specialists charge more than the specified amount that your medical aid will pay out for both in- and out-of-hospital procedures. Therefore, as long as it is from a risk or hospital benefit, this where gap cover kicks in and Stratum will pay an additional cover of up to 500% of Medical Scheme Tariff for its member.
If all claim related documentation has been correctly submitted, a claim should be paid out within three (3) weeks of submission. Stratum claims are paid into a player’s nominated account and to the service provider should a discount be negotiated directly with the provider. Should this be the case, Stratum will keep the member informed on the process.
- Day-to-day claims
- Any claims of out-of-hospital procedures or appointments
- Claims not approved or excluded by your medical aid
- Any penalty co-payment, deductible or limitation applied to your medical aid benefits for non-adherence to rules or authorisation procedures (unless otherwise specified)
- A co-payment that is not a fixed Rand amount, except in the case of oncology co-payments
- Claims older than six (6) months
- External appliances and prostheses
- Upfront or deposit fees for healthcare providers
- Robotic surgery
- First-time diagnosis stage 1 breast and prostate cancer
- Fertility treatment
- Costs related to medical reports
- Riots, wars, political acts, terrorism
Please see the Members Letter for more information about what is covered and if you have any further questions, please contact Lionel or Anne at NMG, SACA’s employee benefits brokers (their details are provided in the letter).