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Aug 13, 2023

Self-payment gaps are available on certain medical scheme plans with a medical savings account (MSA). A self-payment gap is activated when you have depleted the funds available in your MSA. You are then required to make payments out of pocket for day-to-day medical expenses before you can claim from Scheme benefits. For example, if you have used all funds available in your MSA for healthcare consultations in the first quarter of the year, you will need to pay for further consultations until you are able to claim again from your medical scheme.

How do self-payment gaps work?

If you have a medical scheme plan with a self-payment gap, you may submit your self-paid medical expenses to your scheme to qualify for above-threshold benefits. The latter benefits are available once you have spent a set amount on approved medical expenses. This set amount is known as a threshold. The size of the self-payment gap, as well as the threshold limit is dependent on your specific benefit option.

Are self-payment gaps beneficial or a risk?

Self-payment gaps are a risk to those who find that they are required to make the gap payments on services rendered before they can claim from their scheme benefits.

Do self-payment gaps affect in-hospital benefits?

Self-payment gaps are only related to out-of-hospital claims. In-hospital cover and chronic medicine are not affected.

Do all medical schemes offer a self-payment gap on their benefit options?

A number of medical schemes in South Africa use this funding model. Bestmed Medical Scheme does not have self-payment gaps. Once your savings are depleted, you have access to your day-to-day benefits. Therefore, you do not have to fund any gap. This is specific to Bestmed’s Pace range.

What should one keep in mind when choosing a benefit option with a self-payment gap?

You will be required to pay for claims for services rendered from your pocket during a self-payment gap until you reach your threshold benefit limit.

Is a co-payment difference to a self-payment gap?

Yes, a co-payment applies:

  • if medicine is prescribed or selected for the treatment of a condition on the chronic disease list (CDL), a prescribed minimum benefit (PMB) or non-CDL and is not listed on the formulary.
  • if the prescribed or selected medicine costs more than the Mediscor Reference Price (MRP).
  • when the provider charges a higher dispensing fee than what the Scheme reimburses.

A formulary co-payment on non-CDL conditions is applicable depending on a member’s chosen benefit option. 

According to the Council for Medical Schemes (CMS), co-payments may not be deducted from your savings account or vested savings account or reimbursed to you.

The co-payment percentage varies according to your chosen benefit option.


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