Share

What is a 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, 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.
  • 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 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.
  • 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.


We live in a world where facts and fiction get blurred
Who we choose to trust can have a profound impact on our lives. Join thousands of devoted South Africans who look to News24 to bring them news they can trust every day. As we celebrate 25 years, become a News24 subscriber as we strive to keep you informed, inspired and empowered.
Join News24 today
heading
description
username
Show Comments ()
Editorial feedback and complaints

Contact the public editor with feedback for our journalists, complaints, queries or suggestions about articles on News24.

LEARN MORE