Available on the Executive, Comprehensive and Priority Plans
The Self-payment Gap (SPG) only applies to the Executive, Comprehensive and Priority Plans. You are in a SPG when you've used the funds in your Medical Savings Account (MSA) before your expenses add up to the Annual Threshold. During this time, you will need to pay for your day-to-day expenses from your own pocket. You cannot claim these expenses back from Discovery Health Medical Scheme.
Claims paid during the self-payment gap for certain day-to-day healthcare services don't accumulate to the respective benefit limits. This includes claims associated with the following benefit limits:
- Dental appliances and Orthodontics
- External Medical Items (EMI)
- Prescribed medicine
- Allied and Therapeutic healthcare services
- Hearing aids
- Optometry
- Antenatal classes
Why you could find yourself in a SPG
- Your MSA amount is smaller than your Annual Threshold.
- You claim for over-the-counter medicine, which we don't add up to your Annual Threshold.
- You or your healthcare professional submits claims from last year, and we pay these claims from the available funds in your MSA for this year. Claims from a previous year don't add up to your Annual Threshold.
- Your MSA pays out claims at Cost.
- You apply for a special payment from your MSA.
- You exceed certain yearly limits, for example dentistry and optical limits.
- You can close the SPG by paying for day-to-day claims from your own pocket until you reach the Annual Threshold. Remember that you must still send your claims to us so that we can process and add them to your Annual Threshold.
Get more information on your SPG from us
To find out whether you're likely to pay costs from your own pocket:
- Check your claim statement; or
- Check your recent claims; or
- Get instant help from our chatbot, Ask Discovery
Remember to continue submitting your claims to Discovery Health Medical Scheme so that we can add them up to your Annual Threshold.