Alexander Forbes Health Digimag

GOOD CHOICES, GOOD HEALTH

Year-end options 2015

HEALTH

Making the choice Your health, your benefits A few things to keep in mind

ALEXANDER FORBES

Foreword

Good choices, good health

Greetings, and welcome to the medical scheme option review season. We know that when it comes to choosing a plan for the year, making the right decision for you and your family is extremely important. That’s why we have made it a top priority to give you all the information you need, in this informative, easy-toaccess electronic format. We hope you not only benefit from, but also enjoy our Zmag. Here’s to helping you make good choices and enjoy good health in 2015.

Regards, Butši Tladi Managing Director Alexander Forbes Health

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GOOD CHOICES, GOOD HEALTH

Contents Important concepts and terms to help you understand your Discovery Health plan

4

Making the choice Why it is important to reassess plan selection once a year

7

How to choose a medical scheme and plan that meets your needs

8

Your health, your benefits Did you know?

The chronic illness benefit

12

Discovery Health Understanding the insured network benefit

14

A few things to keep in mind

Complaints: Tel 011 669 7026 Fax 011 263 1343 contactus@aforbes.co.za www.alexanderforbes.co.za

Hospital Networks 2015 The KeyCare and Delta series

18

Exclusions 2015 The KeyCare series

22

Contributions 2015

24

Various copayments and deductibles

27

Understanding the self-payment gap (SPG)

30

Medical inflation and its effect on medical scheme increases

32

More helpful information Downloads

34 3

ALEXANDER FORBES

Important

concepts and terms to help you understand your Discovery Health plan Discovery Health rate (DHR) This is the rate set by the Discovery Health medical scheme at which your claims and services for healthcare providers (hospitals, pharmacies and healthcare professionals) will be paid.

Payment arrangements Discovery Health has entered into payment arrangements with various healthcare professionals that have agreed to be reimbursed at the Discovery Health rate (DHR). This ensures that you have no copayments. You benefit from access to a broad range of GPs and specialists.

Networks Some of the Discovery plans, benefits and healthcare services require you to use Discovery’s network of providers. If you use these providers Discovery can keep your contributions as affordable as possible while ensuring full cover.

Medicine list This is a list of approved chronic medicines that Discovery covers in full. The list includes an extensive range of medicines for all covered chronic conditions to ensure you always have an option of full cover.

Limits There are some healthcare services such as dentistry and optometry that are subject to annual limits on certain plans. It is important for you to familiarise yourself with the limits applicable to your selected plan. You are also able to track your usage by logging onto www.discovery.co.za or checking your claim statements.

Hospital cover Discovery covers you in hospital for emergency and planned hospital admissions. You have to get authorisation from Discovery for your hospital stay. Your hospital cover is made up of your hospital account and related accounts. A related account is an account from your treating doctor, anesthetist and any other approved healthcare service provider such as pathologists or radiologists.

Medical savings account (MSA) When you join the scheme or at the beginning of every year, an amount is set aside for you to use for your day-to-day healthcare expenses such as GPs, optometry, pathology, medicine and radiology as long as you have money available. Money not used at the end of the year will be carried over to the next year.

Self-payment gap (SPG) This is a temporary gap in cover when you run out of funds in your medical savings account (MSA) but have not yet reached your annual threshold. You will have to pay for day-to-day claims from your own pocket during this period. You must still submit claims you have paid to Discovery so that they know when to start paying from your above threshold benefit (ATB).

Insured network benefit (INB) This benefit gives you day-to-day cover for a set of healthcare services at a network provider when you have spent the annual funds in your MSA. These healthcare services include GP consultation fees, pathology, maternity costs, day-to-day medication and external medical items. The level of cover and limits depend on the plan you choose.

Above threshold benefit (ATB) The ATB gives you extra cover at the Discovery Health rate or a percentage of it when your claims add up to a set amount called the annual threshold. The ATB applies to the Executive Plan, Comprehensive Series and Priority Series. The ATB has a limit on the Priority series.

Chronic illness benefit (CIB)

These are conditions which all medical schemes are required to cover as set by the Council of Medical Schemes according to clinical guidelines. You may be required to use a designated service provider (DSP).

The chronic illness benefit covers a list of chronic conditions that includes asthma, diabetes, high cholesterol and high blood pressure.

The chronic disease list (CDL) is a defined list of chronic conditions that Discovery covers according to the prescribed minimum benefits.

Executive and Comprehensive Plans offer cover for additional chronic conditions. You have full cover for approved medicine on the scheme’s medicine list, or up to a set monthly chronic drug amount (CDA) for medicine not on the medicine list. The CDA is a monthly maximum amount Discovery will pay for a class of medicine.

Designated service provider (DSP)

Preventive screening

A DSP is a hospital or healthcare provider who has an agreement with the Discovery Health medical scheme to provide treatment or services at a contracted rate and without any copayments by you.

The screening and prevention benefit covers certain tests like blood glucose, blood pressure, cholesterol and body mass index (BMI) when done at any one of the Discovery wellness network providers. A list of these providers is available on the Discovery website. Discovery also covers a mammography, pap smear, PSA (prostate screening test) and HIV screening tests. Members 65 years or older and members registered for certain chronic conditions are also covered for seasonal flu vaccines.

Prescribed minimum benefit (PMB) conditions

Day-to-day cover Day-to-day cover includes your visit to healthcare professionals out of hospital as well as radiology, pathology and medicines purchased for everyday use. Discovery covers your day-to-day healthcare services

4

from the medical savings account (MSA), insured network benefit (INB) and above threshold benefit (ATB). The level of day-to-day cover you have depends on the plan you choose.

GOOD CHOICES, GOOD HEALTH

MAKING THE CHOICE

5

ALEXANDER FORBES

Risk tends to increase with age so you should adjust your medical aid as you move on through life’s many stages.

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GOOD CHOICES, GOOD HEALTH

Why

it is important to reassess plan selection once a year The end of the year is a time when many people look forward to a well-deserved break, summer, sun and that long-awaited family holiday. It is also the time of the year when medical schemes announce their benefit changes and contribution increases for the new year. Most people are under the impression that reviewing their medical scheme option is timeconsuming and too complicated and as a result, they choose to stay on their current option. A conversation with your Alexander Forbes healthcare consultant can help make sure that you know your benefits well and that you’re comfortable your present cover meets your needs.

Why it is important to reassess plan selection once a year?

A new addition to the family or planning a baby in the future is a good reason to rethink your plan option. Young children are exposed to all kinds of illnesses and families with very young children fall into one of the highest claims categories on any medical scheme. Premature labour is a trend that is unfortunately on the rise. Premature birth ranks among the top ten highest costs and has the most frequent admissions in the industry for the last few years.

Changes in your health could mean that your existing option is no longer suitable for your needs. Risk tends to increase with age so your medical aid should be adjusted as you move on through life’s many stages. Your chronic illness needs might change.

Even though all medical schemes make provision for 27 chronic conditions, not all options give the same cover for medicines. The comprehensive options usually cover more chronic conditions and offer more comprehensive benefits.

Planning a procedure or operation? Do you know if there are sublimits, copayments or deductibles on your option? Do you know at what rate your option will reimburse your providers?

By analysing your current option your healthcare consultant can advise you on possible solutions.

Then again, you may be overinsured and could save yourself some money by reducing your level of cover.

Or, you may have both healthy and sick members in your family. By analysing your current option your healthcare consultant can advise you on possible solutions. As an example, a solution might be to split the family scheme membership.

Most schemes have options with GP and hospital networks and regularly review these networks, adding to and removing from their network listings.

If you are not aware of this, you might have to pay a penalty. Familiarise yourself with the network that may apply to you to make sure you get the most of the benefit.

Your consultant will analyse your health need to determine just what type of cover you and your family buy. So, before you go on that well-deserved holiday break, make time to check in with your healthcare consultant and make sure you have all the information you need to. Remember, good choices, good health.

Happy holidays!

7

ALEXANDER FORBES

How to

choose a medical scheme and plan that meets your needs

It is important that at least once a year you think about your current medical aid cover and ask yourself some questions such as:

8

1

Is my current plan option still the right amount of cover for the price I am paying?

2

How closely will my current cover continue to meet my and my family’s needs in the new year?

GOOD CHOICES, GOOD HEALTH

It is important that you assess your own and your dependants’ usage of healthcare services over the past two or three years and based on the trends that emerge, also consider what kind of cover you may need in the near future. Remember also to look at what your desired cover will cost you.

You can request a claims transaction history (CTH) for as far back as you want, directly from Discovery Health. Your CTH will show you the claims that you

have made over the period you’re reviewing. This will allow you to see what you have spent both in and out of hospital.

Look at the benefits available in 2015 on your present plan and compare them with the benefits this plan has offered in 2014. If you have experienced any shortfalls in 2014, it may mean that you need to look at a diferent plan, reducing the impact of shortfalls on your pocket in 2015.

Remember that when changing your plan you need to make sure you have thought about the differences in the plan you want to move to.

Those differences include:

■■In-hospital reimbursement rates and sublimits may apply in hospital.

■■Chronic illness benefit requirements, which will tell you if your chronic condition and medication continue to be covered.

■■Copayments applicable both in and out of hospital.

■■The amount of money that will be available for the year for your day-to-day expenses.

If you wish to change your plan, remember you need to communicate your change with your employer if currently employed, or directly with Discovery Health.

Remember, good choices, good health.

Have a great 2015!

9

ALEXANDER FORBES

A quick way to assess your medical scheme and plan

New addition to the family or planning a baby in the future?

YES to any of these

Changes in your health?

NO to all Planning a procedure or operation?

Do you think you are overinsured?

It is time to rethink your plan option.

Contact your healthcare consultant for an analysis to determine just what type of cover you and your family need.

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Great, your plan option is still working for you.

GOOD CHOICES, GOOD HEALTH

YOUR HEALTH, YOUR BENEFITS

11

ALEXANDER FORBES

Did you know?

Here are some interesting facts and helpful hints on Discovery Health’s chronic illness benefit (CIB)

Discovery Health provides a chronic medication benefit on all of their plans for 26 prescribed minimum benefits (PMB) chronic conditions. This defined list of conditions is called the chronic disease list (CDL). Discovery Health further offers cover for an additional disease list (ADL) of 34 chronic conditions on the Comprehensive and Executive plans, meaning that on the Executive and Comprehensive plans, a total of 61 chronic conditions are covered under the CIB.

MedXpress is a courier pharmacy available to all Discovery Health members, providing delivery of your chronic medication either to your home or place of work. If you are on a Delta plan it is compulsory to receive your chronic medication through MedXpress. It is easy to register for MedXpress and you can do it in the following way:

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As this is not an automatic benefit, you and your doctor will need to complete a chronic illness application form. Certain supporting tests may be required as well. The turnaround time for these applications is 48 hours. Discovery Health provides a list of medicines that are covered in full. Should your medication not form part of this list Discovery Health may pay a limited amount monthly known as the chronic drug amount (CDA) towards the medication.

■■Send in your prescription, with your name and membership number written on it to either medxpress@discovery.co.za or fax it to 011 539 1020.

■■Once your prescription has been processed you will receive an sms telling you to call MedXpress to place your order. Remember to allow 3–5 working days for your medication to be delivered.

■■When you need to re-order your medication Discovery Health will send you a reminder sms to place your order. You can use the online Discovery Health application, phone or send a sms.

GOOD CHOICES, GOOD HEALTH

If you belong to a KeyCare plan your chosen GP can dispense your chronic medication. Alternatively, a KeyCare member may receive their medication from one of Discovery Health’s network pharmacies.

Once your chronic condition is registered with the chronic department you can change your medication by sending in an updated script to Discovery Health. Remember, Discovery Health needs an updated script from you every six months. Current legislation requires you to visit your doctor and manage your chronic condition.

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ALEXANDER FORBES

Discovery Health Understanding the insured network benefit

Discovery Health offers further cover for medical expenses from the insured network benefit on the Saver, Priority, Comprehensive and Executive plans.

The insured network benefit will pay for defined medical expenses for members on these plans whose savings have finished or who are in their selfpayment gap.

This benefit is only available on plans with a medical savings account (MSA). Note that it is not available on Classic Comprehensive Zero MSA, Core and KeyCare plans.

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During these gaps Discovery Health will provide extended cover for the following according to your plan:

■■ GP consultation fees ■■ Blood tests ■■ Day-to-day cost-effective medicines ■■ Maternity benefit ■■ A defined list of durable external medical items

GOOD CHOICES, GOOD HEALTH

What you need to know to access these benefits

GP consultation fees (Executive, Comprehensive, Priority and Saver Plans) ■■ The insured network benefit will cover GP consultations (procedure codes 0190, 0191 and 0192) only.

■■ Your GP must be part of the Discovery Health GP network. If you visit any other GP, the consultation will be paid according to the day-to-day benefits available on your chosen health plan.

■■ This benefit does not cover materials, procedures or other healthcare services at your GP in the Discovery Health GP network. These are paid for from your available day-to-day benefits.

■■ Claims paid from the insured network benefit do not add up to the annual threshold.

Blood tests (Executive, Classic Comprehensive, Classic Delta Comprehensive and Classic Priority Plans) The insured network benefit also covers for outof-hospital pathology on the Executive, Classic Comprehensive, Classic Delta Comprehensive and the Classic Priority Plans.

Tests should be done within the Discovery network of pharmacies and pathologists. Your GP or

pathologist doesn’t have to use the Discovery Health pathology form.

These tests must be done at one of the partners: ■■ Clicks ■■ Dis-Chem ■■ Pick n Pay 15

ALEXANDER FORBES

Day-to-day cost-effective medicines (Executive, Classic Comprehensive and Classic Delta Comprehensive Plans) You have full cover for certain cost-effective branded and generic medicines through the introduction of the preferred medicine list. These medicines (schedule 3 and above) will be covered in full when you use a pharmacy in the Discovery network.

The list of network partners ensures that you are never charged more than the Discovery Health rate and you will always be billed the lowest dispensing fees.

You can obtain your medication from the following partners: ■■ Discovery MedXpress ■■ Clicks

■■ Dis-Chem ■■ Pick n Pay ■■ MediRite Medicine not on the preferred medicine list, both branded and generic, will be covered up to 75% of the Discovery Health rate once you reach your annual threshold and 90% on the Executive Plan.

This benefit is available on the Executive, Classic Comprehensive and Classic Delta Comprehensive Plans and subject to the prescribed medicine limit per plan type.

Maternity cover (Executive, Classic Comprehensive, Classic Delta Comprehensive, Classic Priority, Classic Saver and Classic Delta Saver) Through the insured network benefit, you have access to gynaecologist or obstetrician consultations and scans that are always paid in full when you use a network provider.

If your plan does not have day-to-day benefits or you have run out of funds on a plan that does not offer the insured network benefit, you must pay these costs yourself.

During the self-payment gap you have access to funding for eight gynaecologist or obstetrician consultations and two 2D scans on the Classic Saver and Classic Delta Saver Plan and unlimited consultations and scans on the Executive, Classic Comprehensive, Classic Delta Comprehensive and Classic Priority plans.

Members on Classic Comprehensive Zero MSA Plan have cover from their above threshold benefit once the annual threshold is reached.

External medical items (Executive, Classic Comprehensive, Classic Delta Comprehensive, Essential Comprehensive, Essential Delta Comprehensive, Classic Priority and Essential Priority)

16

Discovery Health created a preferred supplier network to further assist all members who require expensive durable medical appliances, such as wheelchairs, scooters, walkers, breathing devices (CPAP, APAP, VPAP, portable oxygen concentrators) and insulin pumps.

Given the preferential rates available through the preferred supplier network, items obtained outside the network or which are not on the defined list of items will be paid up to the Discovery Health rate and no insured network benefit cover will be available.

By using the Discovery network you will benefit from: ■■ Lower prices, which means the money in your medical savings account will last longer ■■ Full cover during the self-payment gap (on plans with an above threshold benefit).

The preferred suppliers are: ■■ CE Mobility ■■ Ecomed ■■ VitalAire ■■ SSEM Mthembu ■■ Roche Diabetes Care

GOOD CHOICES, GOOD HEALTH

A FEW THINGS TO KEEP IN MIND

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ALEXANDER FORBES

Hospital Networks 2015 The KeyCare and Delta series

Area

Hospitals

KeyCare Core/Plus* Access**

Delta plans ***

Eastern Cape East London

Life Beacon Bay Hospital

ü

East London

Life St James Operating Theatres

ü

East London

Life East London Private Hospital

ü

East London

Life St Dominic’s Private Hospital

ü

Humansdorp

Life Isivivana Private Hospital

ü

Kokstad

NetCare Kokstad Hospital

Port Elizabeth

Life New Mercantile Hospital

ü

Queenstown

Life Queenstown Private

ü

Uitenhage

Netcare Cuyler Clinic

ü

Uitenhage

Netcare Uitenhage Hospital

Umtata

Life St Mary’s Private Hospital

ü

Bethlehem

Mediclinic Hoogland

ü

Bloemfontein

Horizon Eye Care Centre

ü

Bloemfontein

Netcare Pelonomi Private Hospital

ü

Bloemfontein

Life Rosepark Clinic / Hospital

ü

Bloemfontein

Life Pasteur Hospital

ü

Bloemfontein

Netcare Universitas Private Hospital

ü

Welkom

Ernest Oppenheimer Hospital

ü

Welkom

Mediclinic Welkom

ü

Welkom

St Helena Hospital

ü

ü ü

ü

ü ü

Free State ü ü ü ü

Gauteng

18

Alberton

Netcare Clinton Hospital

Bedfordview

Life Bedford Gardens Hospital

Benoni

Life The Glynwood Hospital

ü

Boksburg

Botshelong Empilweni-clinic (Clinix Vosloorus)

ü

Boksburg

Sunshine Centre

ü

Brakpan

Life Dalview Clinic

ü

Fourways

Life Fourways Hospital

Germiston

Life Roseacres Clinic

ü

ü

Heidelberg

Life Suikerbosrand Clinic

ü

ü

Johannesburg

Netcare Rand Clinic

ü

ü

ü ü

ü

ü

GOOD CHOICES, GOOD HEALTH

KeyCare

Delta plans ***

Area

Hospitals

Johannesburg

Mediclinic Morningside

Johannesburg

Johannesburg Eye Clinic

Johannesburg

The Donald Gordon Medical Centre

Johannesburg

Netcare Garden City Clinic

ü

Johannesburg

Life Brenthurst Clinic

ü

ü

Kempton Park

Arwyp Medical Centre

ü

ü

Krugersdorp

Netcare Krugersdorp Hospital

Lakefield

Netcare Optiklin Eye Hospital

ü

Lenasia

Lenmed Clinic

ü

ü

Midrand

Life Carstenhof Clinic

ü

ü

Pretoria

Netcare Bougainville Private Hospital

ü

ü

Pretoria

Centurion Eye Hospital

ü

Pretoria

Netcare Femina Hospital

Pretoria

Life Little Company of Mary

Pretoria

Life Eugene Marais Hospital

ü

Pretoria

Netcare Jacaranda Hospital

ü

Pretoria

MediClinic Legae

ü

ü

ü

Pretoria

Louis Pasteur Hospital

ü

ü

ü

Pretoria

Mediclinic Medforum

ü

Pretoria

Muelmed Hospital

ü

Pretoria

Pretoria Eye Institute

ü

Pretoria

Zuid-Afrikaans Hospital

ü

Randfontein

Life Robinson Private Hospital

ü

Randfontein

Lenmed Randfontein private hospital

ü

Roodepoort

Life Wilgeheuwel Hospital

Sasolburg

Netcare Vaalpark Hospital

ü

Saxonworld

Genesis Clinic

ü

Soweto

Clinix Private Hospital – Tshepo Themba

ü

Soweto

Clinix Private Hospital – Lesedi

ü

Springs

Life Springs Parkland Clinic

ü

Springs

Life St Mary’s Women’s Clinic

ü

Springs

Netcare N17 Hospital

Thembisa

Zamokuhle Private Hospital

ü

Vanderbijlpark

Emfuleni MediClinic

ü

Vanderbijlpark

Ocumed

ü

Vereeniging

Clinix Private Hospital – Sebokeng

ü

ü

Vereeniging

Midvaal Private Hospital

ü

ü

Westgate

Medgate Day Clinic

ü

Netcare Kingsway Hospital

ü

Core/Plus* Access**

ü ü ü

ü

ü

ü ü

ü ü ü ü ü

ü

ü ü ü

KwaZulu-Natal Amanzimtoti

ü 19

ALEXANDER FORBES

KeyCare

Area

Hospitals

Chatsworth

Life Chatsmed Garden Hospital

ü

Durban

Life City Hospital

ü

Durban

Life Entabeni Hospital

ü

Durban

Ethekwini Hospital

Durban

McCord Hospital

Empangeni

Life Empangeni Garden Clinic

ü

Isipingo

Life Isipingo Clinic

ü

Kokstad

Kokstad Private Hospital

ü

Ladysmith

La Verna Hospital

ü

Newcastle

Newcastle Private Hospital

ü

Phoenix

Life Mount Edgecombe Hospital

ü

Pietermaritzburg

Midlands Medical Centre

ü

Pietermaritzburg

Netcare St Anne’s

ü

Pinetown

Life Crompton Hospital

ü

Port Shepstone

Hibiscus Hospital

ü

Richards Bay

Netcare The Bay Hospital

ü

Sydenham

Nu Shifa Hospital

ü

Tongaat

Victoria Private Hospital

ü

Westville

Life Westville Hospital

Core/Plus* Access**

ü ü ü ü

ü

ü ü

ü ü ü

Lesotho Lesotho

Willie’s Hospital

ü

Bela-Bela

St Vincent’s Hospital

ü

Phalaborwa

Clinix Phalaborwa Private Hospital

ü

ü

Polokwane

MediClinic Limpopo

ü

ü

Thabazimbi

MediClinic Thabazimbi

ü

Tzaneen

MediClinic Tzaneen

ü

Barberton

Eureka Private Hospital

ü

Emalahleni/Witbank

Life Cosmos Hospital

ü

Emalahleni/Witbank

Emalahleni Day Hospital

ü

Ermelo

Ermelo Private Hospital

ü

Middelburg

Life Middelburg Private Hospital

ü

Nelspruit

Mediclinic Nelspruit

ü

Piet Retief

Life Piet Retief

ü

Trichardt

Mediclinic Highveld

ü

Brits

Mediclinic Brits

ü

Carletonville

Leslie Williams Private Hospital

ü

Carletonville

Western Deep Clinic

ü

Limpopo

ü

Mpumalanga

North West

20

Delta plans ***

ü

GOOD CHOICES, GOOD HEALTH

KeyCare

Delta plans ***

Area

Hospitals

Klerksdorp

Life Anncron Clinic

ü

Mafikeng

Victoria Private Hospital

ü

Orkney

West Vaal Clinic

ü

Potchefstroom

Mediclinic Potchefstroom

ü

Rustenburg

Life Peglerae Hospital

ü

Rustenburg

Netcare Ferncrest

Vryburg

Vryburg Private Hospital

ü

Kathu

Mediclinic Kathu

ü

Kimberley

Mediclinic Kimberley

ü

Upington

Upington Private Hospital

ü

Bellville

Bellville Medical Centre

ü

Bellville

Mediclinic Louis Leipoldt

ü

Cape Town

Netcare Christiaan Barnard Memorial Hospital

ü

Cape Town

Netcare UCT Medical Centre

ü

Cape Town

Mediclinic Cape Town

ü

Cape Town

Vincent Pallotti Hospital

ü

Cape Town

Cape Eye Hospital (added)

ü

Ceres

Ceres Private Hospital

ü

Gatesville

Gatesville Medical Centre

ü

George

Geneva Clinic

ü

George

Mediclinic George

ü

Hermanus

Mediclinic Hermanus

ü

Kuilsriver

Netcare Kuils River Private Hospital

ü

ü

Milnerton

Mediclinic Milnerton

ü

ü

Mitchells Plain

Mitchells Plain Medical Centre

ü

ü

Mossel Bay

Bayview Hospital

ü

Oudtshoorn

Cango Day Clinic

ü

Oudtshoorn

Mediclinic Klein Karoo

ü

Paarl

Mediclinic Paarl

ü

Parow

Mediclinic Panorama

ü

Somerset West

Mediclinic Vergelegen

ü

West Coast

Life West Coast Private Hospital

ü

Worcester

Mediclinic Worcester

ü

Core/Plus* Access**

ü

Northern Cape ü

Western Cape

ü

ü

ü

* This list applies to the KeyCare Core and Plus plans as well as to the KeyCare Access plan but only for life-threatening emergencies and defined trauma events. ** This list applies to the KeyCare Access plan, but only for childbirth and care for newborns. *** The list does not include the 70+ day clinics where members can get treatment without paying an amount upfront.

Please note that the list of hospitals is subject to change. You can go to www.discovery.co.za for the latest list of hospitals.

21

ALEXANDER FORBES

Exclusions 2015 The KeyCare series

In addition to the general exclusions that apply to all plan options, the KeyCare Series does not cover the following, unless it is a prescribed minimum benefits:

22

1

Hospital admissions related to:

2

Correction of hallux valgus/bunion and tailor’s bunion/bunionette

3

Arthroscopy

4

Removal of varicose veins

■■ Dentistry ■■ Nail disorders ■■ Skin disorders including benign growths and lipomas ■■ Investigations and diagnostics ■■ Functional nasal surgery ■■ Elective caesarean section, except if medically necessary ■■ Surgery for oesophageal reflux and hiatus hernia ■■ Back and neck treatment or surgery ■■ Joint replacements, including but not limited to hips, knees, shoulders and elbows ■■ Cochlear implants, auditory brain implants and internal nerve stimulators – this includes procedures, devices and processors ■■ Healthcare services that should be done out of hospital and for which an admission to hospital is not necessary

GOOD CHOICES, GOOD HEALTH

5

Refractive eye surgery

6

Non-cancerous breast conditions

7

Healthcare services outside South Africa

Discovery Health does not cover the cost of treatment for any complications or the direct or indirect expenses related to any of these excluded conditions and treatments.

23

ALEXANDER FORBES

Contributions 2015 Discovery Health

Total monthly contributions 2015 Series

Plan

Principal member

Adult dependant*

Child dependant*

Executive

Executive

R4 547

R4 547

R863

Comprehensive

Classic Comprehensive

R3 696

R3 496

R737

Classic Delta Comprehensive

R3 329

R3 149

R662

Classic Comprehensive Zero MSA

R2 772

R2 622

R553

Essential Comprehensive

R3 105

R2 936

R625

Essential Delta Comprehensive

R2 796

R2 642

R561

Classic Priority

R2 478

R1 950

R992

Essential Priority

R2 130

R1 672

R850

Classic Saver

R2 172

R1 710

R869

Classic Delta Saver

R1 734

R1 368

R697

Essential Saver

R1 725

R1 294

R690

Essential Delta Saver

R1 378

R1 036

R552

Coastal Saver

R1 710

R1 282

R688

Classic Core

R1 617

R1 272

R646

Classic Delta Core

R1 294

R1 018

R517

Essential Core

R1 389

R1 040

R557

Essential Delta Core

R1 110

R833

R445

Coastal Core

R1 195

R896

R477

KeyCare Plus (R10 001+)

R1 592

R1 592

R426

KeyCare Plus (R7051 - R10 000)

R1 069

R1 069

R300

KeyCare Plus (R361 - R7 050)

R764

R764

R276

KeyCare Plus (R0 - R360)

R330

R330

R330

KeyCare Access (R10 001+)

R1 556

R1 556

R420

KeyCare Access (R7 051 - R10 000)

R1 036

R1 036

R292

KeyCare Access (R4 401 - R7 050)

R718

R718

R258

KeyCare Access (R0 - R4 400)

R538

R538

R235

KeyCare Core (R10 001+)

R1 176

R1 176

R265

KeyCare Core (R7 051 - R10 000)

R762

R762

R187

KeyCare Core (R0 -R7 050)

R611

R611

R158

Priority Saver

Core

KeyCare

*C ontributions are charged up to a maximum of three children; dependants 21 years and older are considered adult dependants.

24

GOOD CHOICES, GOOD HEALTH

2015 medical savings account (included in the monthly contribution on page 24, where applicable) Principal member

Adult dependant

Child dependant

Annual

Monthly

Annual

Monthly

Annual

Monthly

Executive

R13 644

R1 137

R13 644

R1 137

R2 580

R215

Classic

R11 088

R924

R10 488

R874

R2 208

R184

Classic Delta

R9 984

R832

R9 444

R787

R1 980

R165

Essential

R5 580

R465

R5 280

R440

R1 116

R93

Essential Delta

R5 028

R419

R4 752

R396

R1 008

R84

Classic

R7 428

R619

R5 844

R487

R2 976

R248

Essential

R3 828

R319

R3 000

R250

R1 524

R127

Classic

R6 516

R543

R5 124

R427

R2 604

R217

Classic Delta

R5 196

R433

R4 104

R342

R2 088

R174

Essential

R3 096

R258

R2 328

R194

R1 236

R103

Essential Delta

R2 472

R206

R1 860

R155

R984

R82

Coastal

R5 124

R427

R3 840

R320

R2 064

R172

Series

Plan

Executive Comprehensive

Priority Saver

2015 annual threshold levels Executive and Comprehensive plans Executive

Comprehensive

Principal member

R13 640

R12 590

Per adult

R13 640

R12 590

Per child*

R2 550

R2 380

*A maximum of three children are counted when calculating the annual threshold

Priority plans Annual threshold

Above threshold limit

Principal member

R10 980

R9 340

Per adult

R8 250

R6 650

Per child*

R3 590

R3 210

*A maximum of three children are counted when calculating the annual threshold and above threshold limit

25

ALEXANDER FORBES

2015 Vitality & KeyFIT contributions Single member

Member with one dependant

Member with two or more dependants

Vitality

R185

R219

R249

KeyFIT

R40

R49

R60

Vitality & KeyFIT

R199

R239

R275

Late joiner penalties Please note these rates are the standard Discovery Health rates and do not take into account any late joiner penalties (LJP) that may be applied to an applicant or to the adult dependant of an applicant older than age 35. Depending on the number of years they have not belonged to a registered South African medical scheme, an additional penalty (a percentage of the contribution) may be added to the member’s monthly contribution, as shown in the table below: Penalty bands

Maximum penalty

1–4 years

0.05 × contributions

5–14 years

0.25 × contributions

15–24 years

0.5 × contributions

25+ years

0.75 × contributions

The LJP is calculated as follows: A = B minus (35 + C) Where: A = the number of years in the first column B = the age of the applicant at the time of application C = the number of years of credible and creditable coverage 26

GOOD CHOICES, GOOD HEALTH

Various copayments and deductibles Cover for endoscopic procedures (gastroscopy, colonoscopy, sigmoidoscopy and proctoscopy) Series

Plan

In-hospital benefits

In the doctor’s rooms

Executive

Discovery will refund specialist doctors at 300% of the scheme rate and at 100% of the scheme rate for other healthcare services, including radiology in or out of hospital. Hospitalisation is paid from the risk benefit and related accounts are funded from the day-to-day benefits.

Comprehensive

Discovery pays the first R2 750 of your hospital account from your available day-to-day benefits. The balance of the hospital account and related accounts are paid from the hospital benefit.

Saver

Discovery pays the first R3 400 of hospital account from available day-today benefits. The balance of the hospital account and related accounts are paid from the hospital benefit.

Core

Member pays the first R3 400 of the hospital account from available day-today benefits. The balance of the hospital account and related accounts are paid from the hospital benefit.

KeyCare

If the procedure can be done out of hospital, for example in the doctor’s rooms, and the member doesn’t go to hospital, the member won’t have to pay a deductible.

Core and Plus

Covered in Discovery’s day surgery network only.

Covered in Discovery’s day surgery network only.

Access

Covered in Discovery’s network of state facilities and in the KeyCare access hospital network if related to emergencies, trauma, childbirth and care for newborns.

Covered in Discovery’s network of state facilities and in the KeyCare access hospital network if related to emergencies, trauma, childbirth and care for newborns.

An upfront payment (deductible) or other copayment could apply to your procedure.

27

ALEXANDER FORBES

Cover for oncology Members are covered from the Discoverycare oncology programme upon diagnosis with cancer. Cancer treatment costs are not limited. Discovery will cover the first R200 000 or R400 000 (depending on the plan type) of the approved cancer treatment over a 12-month cycle. If the treatment exceeds these limits, members will have a 20% copayment on the additional costs. Cancer treatment that is a prescribed minimum benefit is paid in full. All cancerrelated healthcare costs are covered up to 100% of the Discovery Health rate. Members may have a copayment if the healthcare professional charges above this rate.

Series

Rand value benefit

Executive and Comprehensive plan

R400 000

Priority, Saver, Core

R200 000

KeyCare

Cancer treatment is covered if it is a prescribed minimum benefits condition in the Discovery network or state facility. Once members have registered, a network provider will be allocated to the member or the member can go to a state facility. A copayment of 20% will be payable if the member chooses any other provider.

MRI or CT scans In-hospital and out-of-hospital benefits Plan series Executive Comprehensive

Saver

Scans are paid at 100% of the scheme rate from the hospital benefit and related accounts are funded from the available day-to-day benefits.

Classic Classic Delta Essential Essential Delta

If the scan is done as part of an approved hospital admission Discovery pays it from the hospital benefit at 100% of the Discovery Health rate.

Classic Zero MSA

Scans are covered once the member reaches the annual threshold.

If the scan is not related to the hospital admission or if for conservative back or neck treatment, Discovery pays the first R2 600 from day-to-day benefits and the balance from the hospital benefit, up to 100% of the Discovery Health rate. Specific rules apply for conservative back and neck scans.

If the scan is done as part of an approved hospital admission Discovery pays it from the hospital benefit at 100% of the Discovery Health rate.

If the scan is not related to the hospital admission or if for conservative back or neck treatment, Discovery pays the first R2 600 from day-to-day benefits and the balance from the hospital benefit, up to 100% of the Discovery Health rate. Specific rules and limits apply to conservative back and neck scans.

Core

If the scan is done as part of an approved hospital admission Discovery pays it from the hospital benefit at 100% of the Discovery Health rate.

If the scan is not related to the hospital admission or if it is done for conservative back or neck treatment, the scheme will not pay any benefits.

KeyCare

28

If the scan is related to approved hospital admission, Discovery will pay from hospital benefit. If not, Discovery will pay it from the specialist benefit, up to R3 000 for each person. Scans related to conservative back or neck treatments are excluded.

GOOD CHOICES, GOOD HEALTH

Dentistry (in-hospital) Members need to pay a portion of the hospital or the day clinic account up front for dental admissions.

This amount varies, depending on the patient’s age and the place of treatment: Category of Members

Hospital

Day clinic

Members younger than 13

R1 700

R800

Members older than 13

R4 400

R2 850

Discovery Priority series (deductibles) Members need to pay an amount up front to the hospital when the member is admitted for one of the following procedures: Deductible amount

Procedure

R2 350

Conservative back and neck treatment Myringotomy (grommets) Tonsillectomy Adenoidectomy

R3 150

Colonoscopy Sigmoidoscopy Proctoscopy Gastroscopy Cystoscopy

R5 650

Arthroscopy Functional nasal procedures Hysterectomy (except for pre-operatively diagnosed cancer) Laparoscopy Hysteroscopy Endometrial ablation

R11 550

Nissan fundoplication (reflux surgery) Spinal surgery (back and neck) Joint replacements

If the procedure can be done out of hospital, for example in the doctor’s rooms, and the member doesn’t go to hospital, the member won’t have to pay a deductible. It is recommended that members contact Discovery Health directly on 0860 100 694 before the procedure to confirm their benefits.

Delta series Members on Delta plans are covered in hospitals and day clinics in the Delta hospital network. For planned admissions at hospitals outside the network, members must pay an amount of R5 950 up front to the hospital.

The deductible does not apply in an emergency.

Members on Delta plans will have a 20% copayment on the cost of the medicine if they don’t use MedXpress as the pharmacy to obtain their chronic medicine.

29

ALEXANDER FORBES

Understanding

the self-payment gap (SPG)

For Executive, Comprehensive and Priority plan members only, there are five reasons you’d need to pay claims from your own pocket before the scheme starts paying again from your above threshold benefit (ATB):

1

Your medical savings account (MSA) is lower than your annual threshold.

2

You are claiming for over-the-counter and non-generic medicines.

3

You choose to have last year’s claims paid from this year’s MSA.

4

Your MSA pays out above the Discovery Health rate.

5

You exceed your annual limits, for example dentistry and optical limits.

This is called a self-payment gap (SPG). It happens when you run out of money in your medical savings account before reaching your annual threshold. To find out whether you’re likely to have a SPG, check:

30

■■Your claim statement ■■Discovery’s website, www.discovery.co.za ■■On your cell phone, sms ‘SPG’ to 31347

GOOD CHOICES, GOOD HEALTH

Remember to keep sending in your claims to Discovery Health even while you’re in your self-payment gap so that they can add up to your annual threshold.

31

ALEXANDER FORBES

Medical inflation and its effect on medical scheme increases

With a view to 2015, Alexander Forbes Health expects to see medical scheme increases continuing to be in excess of current consumer price inflation rates (CPI).

It is both a South African and international trend that healthcare inflation outstrips general inflation.

We know that CPI is the basic measure of inflation in South Africa, and so it stands to reason that any driver of medical inflation which increases in excess of current CPI rates would have a negative effect on medical inflation.

Some major factors that have contributed to medical inflation over the last five-year period: ■■ The average private hospital tariff has increased by between 8% and 13%.

■■ Specialist or professional fees have increased by 9%.

■■ The acute and chronic medication price increase has been estimated to be as high as 8%.

■■ The usage and ageing impact to larger schemes ranges from 1.0% to 2.0% and smaller schemes between 2.0% and 3.0%. Usage impact of factors like HIV and Aids, technological advances in treatment, diagnostics and medication as well as industry regulation ranges from 1.0% to 5.0%.

■■ Building reserves have increased to the required statutory level of 25%.

■■ The need for benefit enhancements.

32

It is clear from the above that the primary causes of medical inflation in South Africa are the escalating costs of hospitalisation and fees charged by medical specialists.

Disease burden and non-communicable diseases such as diabetes, high blood pressure and high cholesterol are contributing to usage increases as well as the cost of medicines to treat serious illnesses.

South Africa has a general shortage of specialist providers, so through the law of supply and demand it stands to reason that these costs will be high.

In light of the above, it is important to understand that medical scheme increases are based on sound financial governance and not on profit motives.

GOOD CHOICES, GOOD HEALTH

MORE HELPFUL

INFORMATION

33

ALEXANDER FORBES

Alexander Forbes member letter Your member letter contains important information about your scheme’s main benefit changes for 2015.

DOWNLOAD

Generic option change form Changing your plan for 2015? You’ll need an option change form.

DOWNLOAD

Benefits to joining Vitality If you’re not already signed up to Vitality, here’s your chance to find out why signing up just makes so much sense.

DOWNLOAD

34

GOOD CHOICES, GOOD HEALTH

Download the Discovery app on your smartphone

Don’t have a smartphone?

If you don’t have a smartphone, but you do have a cellphone that has sms capability, you can use the short-code sms service known as ‘Discovery Mobile’. Simply sms the appropriate word or abbreviation to 31347 to check any of the following:

Word or abbreviation

You will get

MSA

Your current medical savings account balance (Applies to some plans only)

Claim

Your most recent claim

SPG

Your potential self-payment gap value (Applies to some plans only)

Plan

Your plan name or type

Member number

Your membership number

35

Contact information Stellenbosch 40 Dorp Street, Stellenbosch PO Box 501, Stellenbosch, 7599 Telephone (SA): 021 809 3777 Telephone (International): +27 21 809 3777 Fax (SA): 021 886 4432 Fax (International): +27 21 886 4432 email: clientspecialist@aforbes.co.za

East London 1st Floor Short Mill House, Quarry Office Park, Berea, East London PO Box 19367, Tecoma, 5214 Telephone (SA): 043 701 4800 Telephone (International): +27 43 701 4800 Fax (SA): 043 721 0028 Fax (International): +27 43 721 0028

Pretoria Alexander Forbes House, 189 Clark Street, Brooklyn, Pretoria PO Box 2435, Pretoria, 0001 Telephone (SA): 012 452 7111 Telephone (International): +27 12 452 7111 Fax (SA): 012 452 7111 Fax (International): +27 12 452 7715

Durban Alexander Forbes Place, 10 Torsvale Crescent, Torsvale Park, La Lucia Ridge Office Estate, La Lucia PO Box 782, Umhlanga Rocks, 4320 Telephone (SA): 031 573 8000 Telephone (International): +27 31 573 8000 Fax (SA): 031 573 8311 Fax (International): +27 31 573 8311

Bloemfontein 8-10 Reid Street, Westdene, Bloemfontein PO Box 12731, Brandhof, 9324 Telephone (SA): 051 403 6500 Telephone (International): +27 51 403 6500 Fax (SA): 011 669 2952 Fax (International): +27 11 669 2952

Cape Town Block A, The Boulevard, Searle Street, Woodstock, Cape Town PO Box 253, Cape Town, 8000 Telephone (SA): 021 401 9300 Telephone (International): +27 21 401 9300 Fax (SA): 021 415 5580 Fax (International): +27 21 415 5580

Port Elizabeth 256 Cape Road, Newton Park, Port Elizabeth PO Box 27972, Greenacres, 6057 Telephone (SA): 041 392 8300 Telephone (International): +27 41 392 8300 Fax (SA): 041 392 8543 Fax (International): +27 41 392 8543

Head office – Sandton Alexander Forbes, 115 West Street, Sandown PO Box 787240, Sandown, 2146 Telephone (SA): 011 269 2690 Telephone (International): +27 11 269 2690 Fax (SA): 011 263 2397 Fax (International): +27 11 263 2397 email: hcclientservices@aforbes.co.za web: www.alexanderforbes.co.za

Alexander Forbes Health (Pty) Ltd Reg No: 2007/01544707 A licensed financial services provider FAIS FSP No: 33471 CMS No: 3064