Understanding the Self Payment Gap

This is the amount a medical aid scheme member has to pay for their own healthcare before the scheme takes over. This occurs when the member runs out of their medical savings account (MSA). Not all medical aid plans will have a Self Payment Gap (SPG). 

How the SPG arises

Some medical aid plans come with a medical savings account attached. This account is used by the member of the medical aid scheme to pay for relatively small medical expenses and can run out during the year. To ensure that members continue to access health care when needed, higher end plans tend to offer an Above Threshold Benefit. This benefit covers medical expenses when the MSA runs out but there’s usually a catch. The above threshold benefit usually kicks in when the member has incurred overall claims that are higher than the amount available in the medical savings account. In other words, you would have to pay for claims using the MSA and then from your own pocket before being able to use the above threshold benefit. This is illustrated in the diagram below.

What’s the rationale behind the SPG?

Medical aid schemes use the SPG for two related purposes:

1. To discourage excessive use of healthcare benefits,
2. To keep medical aid contributions affordable.

Without the SPG, medical aid members would be encouraged to quickly finish their MSA and then obtain cover from the above threshold benefit. This would lead to increased costs for the scheme. Since contributions  are meant to cover costs, higher costs mean higher contributions to meet these costs in future years. The Self Payment Gap is intended to protect schemes from such a scenario.