Ever wondered what half the stuff means on medical aid quotations when they talk about 100%, 150% etc.? Medical aid quotations and brochures often state that they will cover your “in hospital” costs at 100% of the scheme’s tariff. Doesn’t that then mean 100% is, well a 100%? Should you be charged more than that, doesn’t that mean you’ll get money back? Not in this case.
The Department of Health published rules and tariffs for specific health services and procedures in and out of a hospital. These tariffs for the Council of Medical Schemes are called the National Health Reference Price List or otherwise known as the NHRPL. They are only a form of guidelines for specialists and anaesthetists to follow when they do charge you for a particular procedure performed while in a hospital.
The scheme rate quotes or brochures refer to a higher than NHRPL rate, about 2 – 5%more depending on the scheme. In other words, should the specialist or anaesthetist charge you 300%, they are charging you three times more that the guided price.
The first step is to make sure at which rate your medical aid scheme is covering you. Should your cover be at a standard 100% rate, you’ll have to negotiate tariffs with the specialist and anaesthetist. Should they charge you more than that tariff which 90% of them do, you’ll have to pay the difference out of your own pocket.
A brain scan with contrast which is only performed in-hospital.
NHRPL rate of 100% covers R 2575.00
Your medical aid covers 300% which means R7 727. 00 is covered.
Should you only be covered for 100% and the specialist charges you 300%, you’ll have to pay R5 151.00 out of your pocket.
It’s for that reason that so many people point fingers to their medical aid and says “but why aren’t you paying for all of this?” The fact is, no one explained to the client how the rates work and now they have to pay all those extra fees from their own pockets.
The first thing that you should do is, get a quote from the specialist who is going to perform the procedure. When you phone your medical aid scheme, ask them how much they will pay for it. Then go back to the specialist and negotiate a tariff.
The second way to cover this is with GapCover. Should your medical aid have a savings plan added to it, you can save 15% of your yearly payments, and that will be used to cover the difference. The costs for this can be anything from R85 to R100 extra per month for an individual.
The third way to avoid such shortfalls is to join a scheme that covers the full 300%, which means you don’t have to negotiate with the specialist to lower their price as it’s all covered.
Do take note that these tariffs only apply to the specialists and anaesthetists in hospitals accounts. The hospital account is usually unlimited, unless you have a different option.
Get a hospital plan with medical aid benefits with your medical aid. Hospital plans like Day1Health for example. Or do what most people are doing today, they settle for a hospital plan with medical aid benefits.