NAMAF is the legislated entity authorised to set benchmark tariff structures on behalf of all medical aid funds. These benchmark tariffs are commonly referred to as the “NAMAF benchmark tariffs”, “scale of benefits” or “medical aid tariffs”. The NAMAF benchmark tariffs used by medical aid funds represent a specific threshold according to which the medical aid fund is willing to reimburse for healthcare treatment and services rendered to the member but in no way limits the healthcare provider to charge more or less than the benchmark tariff, subject to their preference.
As such, the Fund pays claims on behalf of its members according to the set NAMAF benchmark tariffs and if a healthcare provider charges above this tariff, the member will be held liable for the difference. Healthcare providers are not limited to charge according to the NAMAF benchmark tariff structure.
Members will remain responsible for settling the full account to the healthcare providers and as such may be required to settle any outstanding amounts.
In the case of hospitalisation and treatment while in hospital, it is often the case that members may run up a significant bill for expenses that are in excess of the NAMAF benchmark tariff. It is for this reason that the additional in-hospital cover (GAP cover) is there to assist members with defraying the cost of huge co-payments. The Fund offers the GAP cover which will automatically be processed and be paid to the healthcare provider as per the benefit allowed per benefit option.
Members with accumulated Roll-Over benefits may also request that such co-payments in respect of out-of-hospital treatment be refunded from their accumulated Roll-Over benefit account or may alternatively also contact NHP for further advice.