Self-payment Gap

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

Claims paid from the Medical Savings Account (MSA) and from the Above Threshold Benefit (ATB), where applicable, will still accumulate towards these benefit limits.

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.