Mind the (Self-payment) gap.


As someone who has medical aid, you may already be on or have been advised to join a product that offers a kind of failsafe feature. This feature is called the Above-Threshold Benefit (ATB), which is a safety net of day-to-day benefit paid for by the scheme and kicks in when you have exhausted your medical savings account. The idea behind this benefit is that you have a financial parachute if your annual day-to-day medical expenses (i.e. visits to the doctor, dentist or optometrist, medication, and certain pathology and radiology services) exceeds the annual amount that you have in your Medical Savings Account (MSA).

When a claim gets paid from MSA, the amount needs to accumulate to your ATB or to your Self-payment Gap (SPG).

However, the ATB doesn’t just kick in once the savings account is depleted. Instead, there is something called an SPG. That is, you will be first required to pay claims out of your own pocket when your savings have run out before you qualify for the ATB.

FYI, the SPG can be calculated by subtracting the annual amount in your savings account from the amount (or threshold) at which the ATB will kick in. So why does this SPG happen?

1. First and foremost, there is literally a ‘gap’ between the amount in your Medical Savings Account and your ATB, with your savings amount being smaller than the threshold.

2. Since the medication amount will only accumulate in the ATB when classified as schedule 3 or above, claiming for over-the-counter medicine (schedule 0-2) will accumulate in your SPG.

3. Having your Medical Savings Account pay claims at cost price/private rate rather than at the Medical Scheme Health Rate.

4. Applying for a special payment from the Medical Savings Account.

5. Either you or your healthcare provider submits claims from the previous year. Since we have just entered into a new year, we must stress that claims from last year Do Not accumulate towards your Annual Threshold. Instead, suppose you submit claims from the previous year November, December (2020) to be processed in the current year (Feb 2021). In that case, these claims will be paid from the available Medical Savings Account and will increase the SPG for the year 2021.

In that case, how do you close your SPG? You can do this by paying for day-to-day claims from your own pocket until you reach the Annual Threshold. However, you need to keep in mind you must still submit all claims along with the proof of payment so that the Medical Scheme can process them and accumulate towards your Annual Threshold.

Phew! This may seem like a lot of information to retain but fear not, the PBA team has got your back! Get in touch with us today if you need assistance with your medical aid or to find out more about your SPG and ATB.


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