Medical aid and gap cover go together like flint and steel. The magic happens when they work together. Similar could be true for GEMS Medical Aid members applying for TRA gap cover to help navigate their medical scheme tariffs (MST) and manage their out-of-pocket expenses.
While GEMS offers a broad selection of medical aid benefit options, members may still experience shortfalls when a provider charges more than the scheme pays. These medical aid shortfalls can occur during hospital stays or when undergoing specialist treatment, even if the treatment is authorised.
Total Risk Administrators (TRA) is a gap cover provider whose plans aim to support medical aid members in bridging these tariff shortfalls by covering co-payments, tariff gaps, and costs not fully paid by the medical scheme.
Why GEMS Members May Choose TRA Gap Cover
The Government Employees Medical Scheme (GEMS) provides over two million public service members and dependents with access to structured medical aid options. This cover is specifically designed for government employees and offers a variety of benefit options to match different income levels and healthcare needs.
Even with this level of cover, members may be responsible for the difference between what healthcare providers charge and what their medical aid scheme reimburses.
Common shortfalls of your current medical aid can include:
- Specialist tariffs above what GEMS pays per its scheme tariff
- Co-payments for certain hospital procedures or scans
- Oncology-related co-payments and sub-limits
- Unexpected costs during planned treatments
Gap cover may be used alongside a GEMS plan to address some of these gaps. It becomes especially valuable during hospital admissions, high-cost treatment, or when using out-of-network providers.
GEMS’ Medical Aid Plan Structure
GEMS offers six main benefit options, each tailored to specific healthcare needs, affordability, and provider access:
Tanzanite One
This option provides access to public hospital services and a network of private providers. It emphasises primary and preventative care, with most services coordinated through a main provider. It is typically the most affordable plan.
Beryl
This entry-level private option includes access to a defined network of GPs, hospitals, and specialists. It provides structured day-to-day and in-hospital benefits, including limited dental and chronic medication cover.
Ruby
Includes a personal savings account, allowing members to manage out-of-hospital medical spending. Offers access to private hospitals and specialists, with structured co-payments for certain services.
Emerald Value
It offers comprehensive hospital cover through network providers and general access to day-to-day services. Due to the use of preferred networks, it has lower contributions compared to the standard Emerald plan.
Emerald
A widely used plan offering full hospital cover without provider network restrictions. Includes out-of-hospital and chronic care support, making it suitable for families and members with more complex healthcare needs.
Onyx
Designed for members aged 60 and older, Onyx provides extended benefits for chronic care, hospital access, and specialist consultations. It reflects the typical healthcare profile of older members and retirees.
Across all plans, GEMS members can access features like the GEMS Member App. The app supports digital tools such as:
- Tracking claims
- Viewing personal profile details
- Downloading tax certificates and policy documents
- Checking benefits, status, and provider access
In addition, GEMS offers a Primary Care Extender Benefit for members on the Emerald and Emerald Value options. This benefit provides additional coverage for specific out-of-hospital services once their standard day-to-day Block Benefit is exhausted.
TRA Gap Cover Policies
TRA offers four gap cover policy tiers, each with different coverage features, allowing members to choose which plan suits them best.
TRA’s Basic Cover 300
Includes up to 300% tariff shortfall cover on in-hospital services, one specialist consultation shortfall per year, and a casualty unit benefit for accident-related events. This policy provides limited benefits for common medical aid shortfalls.
TRA’s Vital Cover Plus
Offers up to 700% shortfall cover. Includes benefits for co-payments, specified dental procedures performed in-hospital, oncology-related shortfalls, and extended casualty support.
TRA’s Super Cover Plus
Provides up to 700% tariff shortfall cover and includes a range of co-payment benefits, multiple specialist shortfall categories, oncology co-payment support, global fee shortfall cover, and private ward support.
TRA’s Absolute Cover Plus
TRA’s most extensive policy. Includes up to 700% shortfall cover, comprehensive oncology support (including extender benefits and selected reconstructive procedures), maternity and private ward benefits, and cover for high-cost prostheses, scans, and scopes.
All TRA policies include access to the TRA Assist app, which enables members to access certain services, manage their profiles and submit claims.
How TRA Gap Cover Works
Gap cover is a supplementary insurance product. It does not replace your medical aid but works alongside it to manage financial shortfalls that occur when treatment costs exceed scheme tariffs.
What TRA Gap Cover Includes
When a GEMS member is admitted to hospital, their medical aid scheme will pay up to a set rate (MSR). If the specialist or hospital charges more than this rate, the member may be held liable for the difference. Should a GEMS member sign up for TRA gap cover, TRA may settle that difference within the annual limit set for cover*.
Depending on your TRA plan, benefits and coverage may include:
- Shortfalls on in-hospital tariffs (up to 700% of medical aid scheme rates)
- Co-payment cover for scopes, scans, and oncology treatments
- Dental gap cover for in-hospital procedures
- Sub-limit cover for prostheses and high-cost treatments
- Oncology extender benefits
- Casualty unit cover for accident-related visits
- Private ward benefits (subject to plan and conditions)
- Maternity consultation support and hospital-related shortfalls
- Accidental death cover and policy continuation on the death of the main member
- Travel insurance (under 71)
- Access to trauma counselling, nursing lines, and 24/7 for emergencies from TRA Assist via the mobile app
Note: *All gap cover policies are subject to an annual limit of R210,580 per insured person currently in 2025 (adjusted annually, effective back to 1 April every year).
TRA’s Approach to Waiting Periods
TRA does not apply a general three-month waiting period. Specific waiting periods apply depending on the condition and treatment history:
- 10 months for scopes, spinal surgery, joint replacements, and childbirth etc.
- 6 months for pre-existing conditions
- 9 months for cancer if diagnosed before joining TRA
If a member signs up within 90 days of leaving another gap cover provider, TRA may waive or reduce certain waiting periods, depending on policy underwriting.
Who Benefits from Gap Cover?
GEMS members across all age groups and plan types may consider TRA gap cover worth it if they:
- Anticipate hospitalisation or scheduled procedures
- Require regular specialist visits for chronic or surgical care
- Want to reduce the risk of unexpected medical expenses
- Prefer to avoid upgrading to a higher-cost benefit option
- Seek more financial predictability during treatment
From young professionals to retirees, TRA’s range of policies may help manage some of the unpredictability when it comes to hospitalisation and medical services.
Claims and Support
TRA offers multiple ways to submit and manage claims:
- Via the TRA website
- Through the TRA app
- Email submission
- Contacting the TRA claims department
All policies include TRA Assist, providing:
- A 24/7 panic button
- Trauma and nurse support lines
- 6 Uber trips per policy per annum
TRA processes claims three times a week, aiming for a fast, reliable turnaround.
Get a Quote With TRA Gap Cover
GEMS supports public servants across the country with structured medical aid plans. But even with comprehensive benefits, cover shortfalls can still occur. TRA may be the perfect match for GEMS Medical Aid members, depending on individual healthcare needs.
Don’t wait until it’s too late and you’re left paying out of pocket. Get a quote or sign up for Gap Cover with Total Risk Administrators (TRA) today.
Disclaimer:
This article was written on behalf of TRA and is intended to provide general information about how TRA Gap Cover may support members of schemes such as GEMS Medical Aid. It is not offering advice. TRA is not affiliated with GEMS. All GEMS plan information is based on publicly available sources as of 2025 and may change. Please consult GEMS directly for current information. Always review the full TRA policy wording to cover terms, limitations, and waiting periods. TRA is underwritten by Auto&General Insurance Company Limited, an authorised financial services provider and licensed non-life insurer.
