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What does “100% of Medical Aid Rate” mean?

What is the “Medical Aid Rate”?

Does “100% of Medical Aid Rate” mean your claims will be settled IN FULL…?

Since July 2010, with the demise of the Department of Health’s National Health Reference Price List (NHRPL), or “Medical Aid Rates” as most people knew it for many years, there has been no uniform guide for medical schemes on which to base their tariff structures for the reimbursement of relevant health services. Since then, there has been no regulation in South Africa that provides a framework to medical providers in terms of what they should charge for their services – they are free to charge whatever they want to charge.
As from 2011, medical schemes have formulated their own tariff and rates structures. The majority of medical schemes have continued to use the term “Medical Aid Rate”, or “scheme rate”. Although the basis used by schemes at that time was the NHRPL, schemes have, over the years, applied their own annual tariff and rates increases. As a result, the gaps in the tariffs and rates of the various schemes have widened; so much so that medical schemes all have their own (unique) “Medical Aid Rates”.

Example

The “Medical Aid Rate” under the NHRPL regime for an in-hospital physician consultation in 2011 was R400. From 2012 to 2018, Scheme A increased their rate for an in-hospital physician consultation by 6.6% annually, whereas Scheme B increased their rate by 5.3% annually.
As a result of the different annual rate increases applied by Schemes A & B, their 2018 “Medical Aid Rates” for an in-hospital physician consultation are the following:

Scheme A – R625.69

Scheme B – R574.19

“Medical Aid Rate” for members of Genesis Medical Scheme means the fixed tariff for payment of relevant health services / benefits in accordance with the Rules of the Scheme, or the fee determined in terms of any agreement between the Scheme and a service provider(s) (i.e. private hospitals) for the payment of relevant health services.

What does “100% of Medical Aid Rate” mean?

If the Rules of the Scheme state that your qualifying claims will be reimbursed at “100% of Medical Aid Rate”, does it mean that your claim(s) will always be settled in full by the Scheme?

Unfortunately NOT.

Hospital accounts will usually be settled in full in terms of the agreement(s) between Genesis and the respective private hospital(s).

All other providers, such as doctors, specialists, pathologists, radiologists, physiotherapists, etc., are however not employed by hospitals and as such, their accounts do not form part of “one global hospital account”. Each provider will submit his/her separate individual claim(s) at a different rate(s), which may, or may not, be in line with the Scheme’s “Medical Aid Rate”.

Depending which benefit option members are on, in-hospital GPs and specialists claims will be reimbursed at 100% or 200% of the “Medical Aid Rate”. Using our earlier example – if the “Medical Aid Rate” for a physician consultation is R625.69, Genesis will settle a claim in this regard at cost up to 100% of “Medical Aid Rate” (cost up to R625.69) on the Private Choice benefit option, or at cost up to 200% of the “Medical Aid Rate” (cost up to 2 x R625.69 = R1 251.38) on the Private, Private Plus and Private Comprehensive benefit options.

Where the service provider (in this instance the physician) charges more than 100% or 200% of the Medical Aid Rate, the shortfall will be for the member’s own pocket (or gap cover, if available).

Can you avoid co-payments?

Yes, often co-payments can be avoided, or reduced.

Where possible, obtain a quote(s) from the service providers that will treat you for an in-hospital event. That way, you can establish upfront what portion of the account will be covered by Genesis and what amount could be for your own account. Always try to negotiate discounts with your service provider(s) so that he/she will not charge you more than what Genesis will cover. In our experience, where this request is made in advance, most service providers are negotiable on their rate and tariff structures.

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