Selfmed Medical Aid Tariffs Explained

Understanding Selfmed medical aid tariffs can be extremely confusing, particularly for the average man in the street because not everyone is familiar with medical scheme terms.

That’s why Selfmed tries to make it simple.

To explain the tariffs more clearly preferably you need to first understand the meaning of the acronyms commonly used.

Abbreviations and Acronyms

BHF – Board of Healthcare Funders effectively represents the various medical schemes, and provides their tariff structure.

NHRPL (or RPL) – National Health Reference Price List.

▪ This is the price list for health services and procedures, and is the medical schemes’ guideline.

▪ Medical schemes use the guidelines to reimburse service providers.

▪ The NHRPL is not always the fee the health care providers charge. They are free to set out their own fees, which explains why the patient often needs to settle the difference in the amount claimed by the service provider, and the amount reimbursed by the medical scheme.

Selfmed Medical Aid Tariffs

MSR – Medical Schemes Rate.

▪ This differs from scheme to scheme.

▪ The Medical Scheme Rates are set according to the specific Medical Aid’s different plans or options.

▪ According to the plan you choose, your medical aid pays the specialist or anaesthetist between 100% and 300% of the medical aid rate.

▪ The scheme rates are usually 2%-5% higher than the NHRPL.

▪ If your scheme covers you 100% of the MSR, you will have to negotiate with a specialist or anaesthetist concerning their tariffs. 90% of them charge up yo 400% more than the MSR. You will have to pay in the difference.

▪ To avoid this, you can join a medical aid scheme that gives you 300%, as an option. You can also get Gap Cover which pays this shortfall.

MMAP– Maximum Medical Aid Price.

▪ This is for all pharmaceutical products.

▪ It guides the health professionals in charging what the medical aids will pay.

ICD10 Code – International Classification of Disease. These codes are used internationally to diagnose and classify the different conditions seen and treated by the various health care providers. They are classified according to their set of specific symptoms.

▪ When you visit a doctor, you’ll get a prescription for medication from the chemist.

▪ The ICD10 code of your illness will be written on the prescription. The chemist will recognize the code and substitute a generic medication, which your medical aid will pay in full. (MMAP)

▪ Whether you are referred for x-rays, physiotherapy, a specialist, or even to hospital, any referral note will contain this ICD10 code.

▪ When each provider claims for their services from the medical aid , they too will provide the same ICD10 code. Your medical aid will reimburse them according to the option you are on, and the MSR of your particular scheme.

▪ The medical aid receives accurate information as to how to pay out.

PMB’s – Prescribed Minimum Benefits.

▪ This is a list of chronic conditions which by law are covered by all medical schemes.

▪ This is regardless of the plan or option you are on.