What Does 100%, 200% and 300% In-Hospital Cover Actually Mean?

The Confusion

If you have ever read your medical aid benefit guide, you have almost certainly seen references to "100% of the scheme rate", "200% of the scheme rate" or "300% of the scheme rate" for in-hospital specialists. Most members have no idea what this means in practice — and schemes do not go out of their way to explain it.

What is the Scheme Rate?

Every medical scheme sets its own tariff — a list of what it considers a fair and reasonable fee for each medical procedure or consultation. This is called the scheme rate (sometimes also called the scheme tariff or medical scheme rate).

The scheme rate is not a fixed national standard. Each scheme sets its own, and they vary. Broadly speaking, most scheme rates are significantly lower than what specialists actually charge.

So What Does 100% Mean?

If your plan covers specialists at 100% of the scheme rate, it means your scheme will pay what it considers a fair fee for that specialist's service. If the specialist charges more than that — which most do — you pay the difference out of your own pocket.

What About 200% and 300%?

A plan that covers at 200% of the scheme rate will pay double the scheme's base tariff. At 300%, it pays triple. The higher the percentage, the more likely the scheme's payment will cover what the specialist actually charges — and the less you will pay out of pocket.

An Example

Suppose your scheme rate for a specific surgical procedure is R5,000:

• At 100% cover — your scheme pays R5,000. If the surgeon charges R12,000, you pay R7,000.

• At 200% cover — your scheme pays R10,000. You pay R2,000.

• At 300% cover — your scheme pays R15,000. The surgeon charges R12,000. You pay nothing and may even receive a small credit.

The Key Question to Ask

When comparing plans, do not just look at the percentage figure. Ask: what is the actual rand amount this plan will pay for my most likely procedures? And what do specialists in my area typically charge? The gap between those two numbers is your real out-of-pocket risk.