It’s not even halfway through the year and your medical savings have run out, leaving you in the dreaded self-payment gap (SPG). Sound familiar?
It’s something that happens to many medical aid members, but about which many are in the dark.
“Approximately 65% of members on plans with a SPG deplete their medical savings account at some point during the year,” reveals Deon Kotze, Discovery Health R&D head.
“Of those members, two thirds reach their annual threshold and receive extended cover for day-to-day healthcare expenses.
What is it?
The SPG is an amount assigned to members, that they must pay in full for day-to-day expenses, once their medical savings have run out. These claims are submitted to the scheme, not for refunding, but to reduce and close the gap – after which the above-threshold benefit takes effect and the scheme again pays for day-to-day claims.
It’s applicable to schemes/plans with an above-threshold benefit (limited or unlimited) – usually top-end plans.
SPGs are mechanisms “which the scheme can use to transfer some of the ‘out of hospital expenses’ risk from the scheme to the member,” adds Jill Larkan, GTC healthcare consulting head. This allows schemes to reduce premiums and make [the plan] appear more attractive.
Your initial self-payment – which can increase – is the difference between your annual threshold and annual savings, Chartered Employee Benefits healthcare specialist Devlin Ross writes here.
That the SPG’s not fixed may be a surprise.
What adds to the gap?
Some claims made from savings, may add to the SPG.
Some reasons why Discovery’s SPG increases:
Tips for closing the gap
SPGs are only reduced by claims members pay for that are at medical aid rates, among other things, writes Ross.
For example, if you pay a GP who charges R500 – and submit the claim to the medical scheme to reduce your SPG – if the medical aid rate for a GP consultation is R320, your SPG will only reduce by R320.
Van Emmenis and Kotze share a few more tips:
Use managed-care benefits. Some schemes offer preventative care benefits, paid from risk, not from savings, including oncology, HIV and diabetes management programmes.
Pharmacists can provide sound advice on some medical problems e.g. rashes or colds.
Pay cash for OTC medicine for less serious ailments. Consider cheaper, effective generics.
Know doctors’/specialists’ rates. Ask what rates your doctor charges and if you’ll be liable for co-payments. If affordability is a concern, look for a provider who charges medical scheme rates.
Register chronic diseases. On regular medication for a chronic illness? You may qualify for chronic medication benefits, which your scheme pays for from risk.
Schemes often have lists of medication covered in full for chronic illnesses, called ‘formularies’. Ask your doctor/pharmacist if your prescribed medicine is covered in full. If not, ask about alternatives.
Pre-authorise all hospital admissions to ensure you’re covered. Ask if copayments or sub-limits apply and how to avoid them. Ask your scheme if you’ll have better cover for planned procedures, by using contracted providers or having the procedure in a doctor’s rooms or day clinic.
Read information (fine print, scheme rules) sent by your scheme or financial advisor.
Use your scheme’s preventative screening benefits (wellness programmes) for regular health checks.
Lead a healthy lifestyle.
GTC has found it more beneficial for members to run a personal savings account, than upgrading to avoid SPGs. “Upgrades usually come with additional benefits in areas members don’t need. Members simply need more day-to-day spending money…this is provided less expensively by their own funding account,” says Larkan.
Discovery offers certain benefits to members in their SPG, including network GP consultations, casualty visits for children, gynaecologist consultations during maternity, and pathology at a network pathologist.
Bonitas’s cost-containment strategies include upskilling GPs to perform minor procedures in their rooms rather than referring patients to specialists; developing managed-care programmes to help members manage chronic conditions more optimally; and creating networks of designated service providers with specific rates.