What does '100%, 150%, 200%, 300% and 400% of scheme tariff' mean?

Medical aid quotes and brochures often state that the scheme will cover your in-hospital costs at 100% of the scheme tariff.

But surely 100% is, well, 100%? If you're charged more than that, aren't you supposed to get money back? Not necessarily in this case.

The Government's Department of Health has published rules and tariffs for specific health services and procedures performed in or out of hospital. These tariffs for the Council for Medical Schemes are called the National Health Reference Price List or NHRPL. They are only a guideline for specialists and anaesthetists to follow when they charge you for a specific procedure performed in hospital.

The scheme rate quotes and brochures refer to is usually slightly higher than the NHRPL rate – about 2 – 5% more, depending on the scheme. This means that, should the specialist or anaesthetist charge you 300%, he is actually charging you three times more than the guide price.

What does this mean to you?

The most important thing for you, is to make sure of the tariff or rate at which your scheme and option cover you.

If your scheme covers you at the normal 100% rate, you will have to negotiate tariffs with the specialist and especially the anaesthetist. If they charge you more than that tariff, which 90% of them do, you will have to pay in the difference, out of your own pocket.

Example:

CT Scan (Brain scan with contrast, only performed in hospital)

- NHRPL rate (100%) covers R2 575.90
- Medical Scheme (300%) covers R7 727.70

If, for instance, your specialist charges a 300% rate and you are only covered at 100% (NHRPL rate), you will need to pay the difference (R5 151.80).

That is why many people point fingers at the medical schemes and ask, "Why are you not paying for everything?" The fact is that nobody ever explains the rates and tariffs fully.

The first way to prevent such a shortfall is to get a quote from the specialist who will be performing the procedure. When you call the scheme for pre-authorisation, ask how much they will pay for it. Then you can go back to the specialist and negotiate a tariff.

The second way to avoid such a shortfall is to get a product, such as GapCover, that will cover the difference between payments. Should the specialist and anaesthetist charge you more, GapCover will cover the difference in cost, up to 300%. The cost for this type of product ranges between R85 and R100 per month for an individual or for the whole family.

The third way to avoid such a shortfall is to join a scheme that already covers you at 300%, which means you don't really have to negotiate with the specialist and anaesthetist.

Please bear in mind that these tariffs are applicable only to the specialist and anaesthetist's in-hospital accounts. The hospital account is usually unlimited, depending on your scheme and option.