What is a self-payment gap?

Self Payment GapDepending on your circumstances and medical expenses through the year, you may well deplete your medical savings account before the year is over. If you and your family have a healthy year with minimal day to day expenses, you could carry money over to the next year. If you have one or more members needing doctor or dentist visits and medication, the opposite might happen and your funds could easily dry up long before the end of the year.

To accommodate this, most medical aids that have plans with an MSA also include an option known as a self-payment gap. This you normally determine yourself when you select your options. Each medical aid scheme and plan has slightly different criteria but how the self-payment gap works is that when you run out of money in the MSA, you will have to pay out of pocket for day to day medical expenses.

During this time, although you are paying for the costs yourself, you continue to submit your medical expenses to the medical aid. Once you have spent an amount of approved medical expenses up to what is known as the threshold that has been set in advance, you will qualify for above threshold benefits.

This applies only to out of hospital day to day expenses and will not affect your in hospital cover or chronic medication.

The self-payment gap gives you greater control over your annual medical costs and peace of mind that if your family does experience unexpectedly high medical costs, you will have some relief. The other advantage of the self-payment gap is that is curbs excessive claims by members which makes the cost of medical aid more affordable. Be aware of the size of our gap and the threshold limit. Be sure to submit claims while making self-payments and understand the process so that you get the maximum benefit from the feature.