Medical aid rates are the rates at which medical schemes in South Africa will cover a treatment or procedure provided by a specialist in a hospital.
In South Africa, The Reference Price List (or RPL) is a set of guidelines published by the Department of Health which outlines the recommended charges for procedures performed in hospital by specialists and anaesthetists. However, health providers like doctors and specialists are not bound by these guidelines, meaning that they can charge what they would like for a procedure (sometimes as much as five times more), as long as they are considered to be of fair value by the patient.
Medical aid rates, then, are often far less than what these specialists charge, though the exact rate you’re quoted will depend on the scheme you’re with and the plan you’re on. Typically, entry-level hospital plans will have a medical scheme rate (MSR) of around 100% of these guideline prices, whereas more comprehensive plans may pay up to 300% of the guideline prices.
So, if a specialist charges 500% of the medical aid rate for a particular procedure or treatment, but your medical scheme only quotes you medical aid rates of 300%, you’ll be liable for the difference between these two amounts.
When choosing a medical aid, find out what medical aid rates the scheme will give you. This will allow you to work out what you’d need to pay in over and above to a particular health provider. In addition, using doctors and specialists within your medical aid’s network means that they’ll most likely charge at the scheme rates – so you won’t need to pay anything extra to cover the difference.
