At some point in everyone’s life they have to consider medical aid rates, whether it is when choosing which medical aid scheme that will best meet their individual health needs, deciding which medical practitioner to consult or deciding whether to ask for a generic medicine. Trying to understand how medical aid tariffs are calculated can be difficult, particularly for those who are not familiar with medical aid jargon and acronyms such as BHF, NHRPL, ICD-10 and PMB and MMAP® (Maximum Medical Aid Price). Each of these terms has a specific meaning that is useful to know when navigating information provided by medical practitioners and medical aid providers.

Until recently, there were three tariff structures in South Africa: the Board of Healthcare Providers (BHF) tariff list, the HPCSA ethical medical rates and the National Health Reference Price List (NHRPL). In January 2004, the BHF tariff was discarded, in December 2008 the HPCSA ceased publishing its suggested rates and only NHRPL rates are currently used. Read on to learn more about how medical aid tariffs are regulated and understand how this change affects you.

Until 2004, the BHF published its own list of recommended tariffs, which was developed through negotiation between the BHF and the South African Medical Association (SAMA).

The  BHF list was ruled in contravention of the competition act, which regulates activity between businesses and organisations that should be competitors. Therefore, the BHF is no longer publishing its list of recommended medical tariffs and this has list been superseded by the NHRPL rates The BHF fully supports the process of deriving the NHRPL tariffs, according to their spokeswomen, Heidi Kruger.

The NHRPL was designed by the Council for Medical Schemes on behalf of the Department of Health and first published in 2004. This list does not contain negotiated prices, and is created by gathering submissions from all disciplines of health service with suggestions regarding the actual cost of running a practice.

Hospitals do not yet take part in the classification process and thus the NHRPL methodology of calculating its rates does not yet pertain to these institutions. Until HASA (Hospital Association of South Africa) and the Department of Health have reached consensus on the methodology that needs to be applied to calculate hospital tariffs, it will remain that medical aid providers  negotiate with these healthcare providers on an individual basis to decide on pricing.

It must be understood that the NHRPL is not always reflective of the actual prices that may be charged at medical practices, but its rates are more of a guideline for practitioners and medical aid schemes around which they can calculate tariff structures and design benefit structures so as to minimise additional payments from insured members.

In the same way that doctors are not bound by the NHRPL, medical aid schemes are free to calculate their own medical scheme rates (MSR rates). Each medical aid scheme tends to use its own Medical Scheme Rate (MSR), which is created using the NHRPL as a guideline.

Historically, there was another list of published rates which HPCSA (Health Professions' Council of South Africa) published: the so-called ethical medical tariffs. The HPCSA announced in November 2008 that it was doing away with these ethical tariffs and, in essence, scrapping the publication thereof.

What remains now is the NHRPL and this is now the de facto reference price list. (RPL)

The change in price regulation has had many repercussions throughout the medical and medical aid communities, but how does it affect the consumer? The new system has undoubtedly filtered down to medical aid members.

There are two different methods of paying a doctor or specialist if a patient has medical aid:

1. Medical aid providers can pay their MSR directly to the patient or member. The patient is therefore responsible for paying the doctor the full amount for the procedure.

2. The medical aid provider can pay the doctor directly. In this case the patient or member will only be expected to contribute financially if the doctor’s fees exceed the provider’s contribution.

Medical aid providers are now unable to predict exactly what a doctor will charge for a specific procedure and will generally provide cover in relation to their MSR. If a particular medical aid scheme provides members with 200% of their MSR and the doctor charges the same amount or less, the patient is completely covered. If, however, the medical practitioner charges 250%, the patient is expected to pay the difference using their own funds.

ICD-10 codes are used internationally as a way to diagnose and classify all diseases and medical ailments. All conditions are categorised according to their specific symptoms. ICD-10 codes are designed to keep doctor’s diagnoses consistent and easily identifiable by other medical practitioners and medical aid providers.

When an individual signs up for a particular medical aid scheme, his or her medical aid provider is agreeing to contribute financially towards treatment of a certain selection of ailments and illnesses. ICD-10 codes are an accurate way to describe any illness or ailment, and they supply medical aid providers with accurate information to help them know how much to pay out. By law, medical aid providers are required to submit the ICD-10 code with all claims.

This list is particularly helpful for members who suffer from ailments for which Prescribed Minimum Benefits (PMB) are applicable. These are health issues that medical aid providers are required, by law, to fund for all of their members, regardless of the medical aid plan they subscribe to.

Deciding which medical aid scheme suits your health requirements best is one of the most important decisions that you can make during your lifetime. It may seem inconsequential now, but it can provide you with immense peace of mind should the unforeseen occur.

It is imperative that you understand exactly what your medical aid provider will contribute towards your treatment. Selfmed medical scheme strives to provide sincere, ethical and secure medical aid cover to all of its members. In general, Selfmed has a 100-200% MSR rate on many if its medical aid options. Always make sure that you understand each plan and review the cover to ensure that you are covered sufficiently for your particular circumstance.