% Coverage
What follows is a very simplified explanation.
For year we had a system where doctors and other providers were either contracted in our out of medically aid rates. Broadly speaking there were two rates of reimbursement to providers for their services, the ones that medical aids set and paid, this was the lower one (RAMS was an example), and the rate that the providers associations set as the private rate( eg SAMA).
As medical evolved most schemes offered a choice of covering you a one of these rates or somewhere in between. The government decided that their was price fixing(competition commission) in the market place and so this system was scrapped.
The National Health Reference Price Lists was then introduced.NHRPL set prices and broadly speaking, with a couple of exeptions, this is what the 100 % rate of most medical schemes is. It looks remarkably similar to the old medical aid rates, inflation adjusted for the years that have passed since then.
Of course no one can force any provider to charge any rate( they are working on that issue, but thats another can of worms altogether) and many specialists do not charge the NHRPL rate. Most charge 300 % of NHRPL, thus alot of schemes provide cover at that rate.
Discovery Health used to provide cover at 300% but could simply not afford to do so for 2007(their annual results are out, they made a underwriting loss last year and their solvency that is supposed to be at 25% slipped from 22 to 18%
https://www.discovery.co.za/downloads/pdf/2006_audited_financial_statements.pdf) Thus they have dropped the cover to 200% and very recently, because of the outcry in the market place over the drops introduced a new very expensive called the Executive plan.
Please understand that if you have less than 300% cover you are at very real risk of having large co payments should you be hospitalized for any reason.
This comes about a result of many specialists refusing to sign up for the Discovery premier rate( which wants providers to do the same work they did last year for alot less money -- be aware that many providers who appear on the Discovery premier rate list do not charge the rate-- Discovery embarked on a negative response campaign, they added all providers to it who did not inform them that they did not want to on the lists, many are only finding out now that they are on the list)
Many providers will continue to charge rates based on 300% of NHRPL, thus if you are on a plan that does 200% you will have to pay the difference.
