Medical Aid Rates and Tariffs Explained

In South Africa, we have a dual health care system – private and public providers. The Medical Schemes Act (1998) regulates those outfits. Each year in December/January, the schemes release their medical aid rates and tariffs.

When comparing you’ll notice that leading medical aid rates in South Africa for 2016 revealed increases up to 0.92%. Medical aid members have had to dig ever deeper. That’s because these rates are higher than the official consumer price index (CPI) inflation average. Members now wonder if they are receiving value for their money. Each plan is priced differently depending on the cover provided. And in many instances, children are charged a reduced contribution.

Specialists Ignore the NHRPL Guideline Prices

Yearly negotiations between medical schemes and hospitals set the tariffs for the year, and these remain fixed throughout the year. Every person with a medical aid needs to read their medical aid’s  brochure to see if their medical aid is still affordable and worthwhile. For instance, if a medical aid says that your plan unlimited in-hospital cover, it means that cover is unlimited at medical aid rates.

Specialists charge 4, 5, and 600 % of the medical aid rate. You just have to do research to see how for example, a specialist will charge R60 000 for cancer surgery where the medical aid tariff is R20 000. So the member has to look frantically for the shortfall of R40 000. Without gap cover, many members put their homes on the market to pay for these deficits. Therefore it is imperative to know how your medical aid’s tariffs will affect you.

Medical Aid Rates and Tariffs
The Department of Health has published certain rules and tariffs for certain services performed in or out of the hospital. These tariffs are known as the National Health Reference Price List or NHRPL. They act as a guideline for specialists to follow when they charge you for treatments and procedures. Most doctors and specialists charge you far more than what the NHRPL lays out as a guide. So if a specialist charges you at 200%, it means they are charging you twice as much like the guided prices of the NHRPL.

With Medical Aid Rates You Pay in Everywhere

If you are eligible for a particular procedure, for instance, you need to be in touch with the medical aid. They will advise you if you have the funds available to pay for it. Going ahead without pre-authorisation will subject you to a co-payment as well. When you put in a claim, the Act regulates the payment of these claims. As a result, the member will receive a statement with all the particulars of the transaction, with the amount charged for all the different services.

If your medical scheme covers at the regular 100% medical aid rates and your doctor charges you more than that, you pay the difference out of your pocket. It is for this reason that people take out gap cover, because it will pay the difference for you, sparing you from having to fork up for huge medical bills.

Should the specialist charge you more, gap cover will cover the difference in cost. The cost of gap cover is roughly anything between R95 and R400 per month. Medical aid members take out gap cover as a necessity. They see it as an ‘unfair’ add-on to an already expensive medical scheme. They see medical aid rates and tariffs as something which is becoming more and more costly with less and less cover.

To add to their woes, if they switch to a more affordable scheme or quit altogether, you must give a month’s written notice of leaving. If you join a medical aid late in life, you’ll also pay more than those who joined early on, which is known as a late joiner penalty.

A Grim Outlook?

Medical aid rates and tariffs are going up, up, up and away. Many people have discarded their medical aids for hospital plans. But how long will it be before this also becomes out of reach?


All info was correct at time of publishing