10 facts on the self-payment gap

This is the time of year when many medical scheme members have exhausted their day-to-day benefits, and move into the so-called 'self-payment gap'.

  • If for argument's sake you have R3500 in your medical savings day-to-day account and you have used it all, many schemes have instituted what they call a 'self-payment gap'.
  • Most full medical schemes give their members a medical savings account (MSA), which is anything from 15 - 25% of their contributions.
  • It may not exceed 25%, according to medical scheme regulations. Once this is exhausted, you move into the territory of the self-payment gap on some scheme options.
  • This self-payment gap varies in size according to the scheme and the option you have chosen.
  • Up to a pre-determined limit (which is different for every scheme) you will be liable for the payments until you reach what is called a threshold.
  • These are called above-threshold benefits and once you're through the self-payment gap many schemes will resume paying for day-to-day medical expenses up to a certain limit.
  • It must be noted that the threshold is determined by the number of dependants you have registered as the main member. And so is the size of the self-payment gap. The more dependants you have, the bigger the self-payment gap - but it also takes longer to get there, as your contributions would be higher than those of a single member, and therefore your MSA also larger.
  • Do remember that your scheme will still pay for things such as chronic medication, hospitalisation and other benefits not covered from the medical savings account.
  • It is important that you continue to submit claims to your medical scheme even when you are in the self-payment gap, otherwise they will not know when you have gone through it and qualify for above-threshold benefits.
  • Most schemes have introduced this system in the last few years, largely because of a general change in claim patterns experienced across the industry.