Alexander Forbes Health Digimag

Year-end options 2015

HEALTH

GOOD CHOICES, GOOD HEALTH

Making the choice

Your health, your benefits

A few things to keep in mind

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-to-access 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 TladiManaging Director Alexander Forbes Health

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ALEXANDER FORBES

ContentsImportant 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

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

Complaints:Tel 011 669 7026Fax 011 263 [email protected]

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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.

Prescribed minimum benefit (PMB) conditions

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).

Designated service provider (DSP)

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.

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

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.

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)

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.

Preventive screening

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.

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

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ALEXANDER FORBES

http://www.discovery.co.za

MAKINGTHE CHOICE


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

ALEXANDER FORBES

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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 time-consuming 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?

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.

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

Happy holidays!

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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:

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?

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ALEXANDER FORBES

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!

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A quick way to assess your medical scheme and plan

It is time to rethink your plan option.

Great, your plan option is still working for you.

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

YES to any of these NO to all

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

Changes in your health?

Planning a procedure or operation?

Do you think you are overinsured?

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ALEXANDER FORBES

YOUR HEALTH, YOUR BENEFITS


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Did you know?

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.

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.

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

■ Send in your prescription, with your name and membership number written on it to either [email protected] 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.

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ALEXANDER FORBES

mailto:[email protected]

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.

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.

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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 self-payment 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.

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

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

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ALEXANDER FORBES

What you need to know to access these benefits

■ 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.

The insured network benefit also covers for out-of-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

GP consultation fees (Executive, Comprehensive, Priority and Saver Plans)

Blood tests (Executive, Classic Comprehensive, Classic Delta Comprehensive and Classic Priority Plans)

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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.

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.

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.

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.

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

Day-to-day cost-effective medicines (Executive, Classic Comprehensive and Classic Delta Comprehensive Plans)

Maternity cover (Executive, Classic Comprehensive, Classic Delta Comprehensive, Classic Priority, Classic Saver and Classic Delta Saver)

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.

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).

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.

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

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

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ALEXANDER FORBES

A FEW THINGS TO KEEP IN MIND


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Area HospitalsKeyCare Delta

plans ***Core/Plus* Access**

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 ü

Port Elizabeth Life New Mercantile Hospital ü ü ü

Queenstown Life Queenstown Private ü

Uitenhage Netcare Cuyler Clinic ü

Uitenhage Netcare Uitenhage Hospital ü

Umtata Life St Mary’s Private Hospital ü ü

Free State

Bethlehem Mediclinic Hoogland ü

Bloemfontein Horizon Eye Care Centre ü ü

Bloemfontein Netcare Pelonomi Private Hospital ü ü

Bloemfontein Life Rosepark Clinic / Hospital ü ü

Bloemfontein Life Pasteur Hospital ü

Bloemfontein Netcare Universitas Private Hospital ü ü

Welkom Ernest Oppenheimer Hospital ü

Welkom Mediclinic Welkom ü

Welkom St Helena Hospital ü

Gauteng

Alberton Netcare Clinton Hospital ü ü

Bedfordview Life Bedford Gardens Hospital ü

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 ü

Germiston Life Roseacres Clinic ü ü

Heidelberg Life Suikerbosrand Clinic ü ü

Johannesburg Netcare Rand Clinic ü ü

Hospital Networks 2015 The KeyCare and Delta series

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ALEXANDER FORBES



Johannesburg Mediclinic Morningside ü

Johannesburg Johannesburg Eye Clinic ü

Johannesburg The Donald Gordon Medical Centre ü

Johannesburg Netcare Garden City Clinic ü

Johannesburg Life Brenthurst Clinic ü ü

Kempton Park Arwyp Medical Centre ü ü

Krugersdorp Netcare Krugersdorp Hospital ü

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 ü ü

Pretoria Life Little Company of Mary ü

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 ü

Randfontein Lenmed Randfontein private hospital ü

Roodepoort Life Wilgeheuwel Hospital ü

Sasolburg Netcare Vaalpark Hospital ü ü

Saxonworld Genesis Clinic ü ü

Soweto Clinix Private Hospital – Tshepo Themba ü

Soweto Clinix Private Hospital – Lesedi ü ü ü

Springs Life Springs Parkland Clinic ü

Springs Life St Mary’s Women’s Clinic ü

Springs Netcare N17 Hospital ü

Thembisa Zamokuhle Private Hospital ü ü

Vanderbijlpark Emfuleni MediClinic ü ü

Vanderbijlpark Ocumed ü

Vereeniging Clinix Private Hospital – Sebokeng ü ü

Vereeniging Midvaal Private Hospital ü ü

Westgate Medgate Day Clinic ü

KwaZulu-Natal

Amanzimtoti Netcare Kingsway Hospital ü ü

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Chatsworth Life Chatsmed Garden Hospital ü ü

Durban Life City Hospital ü

Durban Life Entabeni Hospital ü ü

Durban Ethekwini Hospital ü

Durban McCord Hospital ü

Empangeni Life Empangeni Garden Clinic ü

Isipingo Life Isipingo Clinic ü

Kokstad Kokstad Private Hospital ü

Ladysmith La Verna Hospital ü ü

Newcastle Newcastle Private Hospital ü

Phoenix Life Mount Edgecombe Hospital ü

Pietermaritzburg Midlands Medical Centre ü ü

Pietermaritzburg Netcare St Anne’s ü ü

Pinetown Life Crompton Hospital ü

Port Shepstone Hibiscus Hospital ü

Richards Bay Netcare The Bay Hospital ü ü

Sydenham Nu Shifa Hospital ü

Tongaat Victoria Private Hospital ü ü

Westville Life Westville Hospital ü

Lesotho

Lesotho Willie’s Hospital ü

Limpopo

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 ü

Mpumalanga

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 ü

Piet Retief Life Piet Retief ü

Trichardt Mediclinic Highveld ü

North West

Brits Mediclinic Brits ü

Carletonville Leslie Williams Private Hospital ü

Carletonville Western Deep Clinic ü

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ALEXANDER FORBES



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 ü

Vryburg Vryburg Private Hospital ü

Northern Cape

Kathu Mediclinic Kathu ü

Kimberley Mediclinic Kimberley ü ü

Upington Upington Private Hospital ü

Western Cape

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 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 ü

Mossel Bay Bayview Hospital ü

Oudtshoorn Cango Day Clinic ü

Oudtshoorn Mediclinic Klein Karoo ü

Paarl Mediclinic Paarl ü ü

Parow Mediclinic Panorama ü

Somerset West Mediclinic Vergelegen ü

West Coast Life West Coast Private Hospital ü

Worcester Mediclinic Worcester 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.

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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:

Exclusions 2015 The KeyCare series

1 Hospital admissions related to: ■ 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

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

3 Arthroscopy

4 Removal of varicose veins

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ALEXANDER FORBES

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.

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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

Priority Classic Priority R2 478 R1 950 R992

Essential Priority R2 130 R1 672 R850

Saver 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

Core 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 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

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

Contributions 2015 Discovery Health

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ALEXANDER FORBES

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

Series PlanPrincipal member Adult dependant Child dependant

Annual Monthly Annual Monthly Annual Monthly

Executive Executive R13 644 R1 137 R13 644 R1 137 R2 580 R215

Comprehensive 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

Priority Classic R7 428 R619 R5 844 R487 R2 976 R248


Saver Classic R6 516 R543 R5 124 R427 R2 604 R217

Classic Delta R5 196 R433 R4 104 R342 R2 088 R174


Essential Delta R2 472 R206 R1 860 R155 R984 R82

Coastal R5 124 R427 R3 840 R320 R2 064 R172

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

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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



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 columnB = the age of the applicant at the time of applicationC = the number of years of credible and creditable coverage

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ALEXANDER FORBES

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.

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.

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

KeyCare 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.

Various copayments and deductibles

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

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MRI or CT scans

In-hospital and out-of-hospital benefits

Plan series

Executive 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.

Comprehensive Classic Classic Delta Essential Essential Delta

Classic Zero MSA

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 apply for conservative back and neck scans.

Scans are covered once the member reaches the annual threshold.

Saver 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 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.

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 cancer-related 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.

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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 treatmentMyringotomy (grommets)Tonsillectomy Adenoidectomy

R3 150

ColonoscopySigmoidoscopy ProctoscopyGastroscopyCystoscopy

R5 650

ArthroscopyFunctional nasal proceduresHysterectomy (except for pre-operatively diagnosed cancer)Laparoscopy HysteroscopyEndometrial ablation

R11 550Nissan 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.

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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.

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

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:

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ALEXANDER FORBES


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.

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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.

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.

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).

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.

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ALEXANDER FORBES

MORE HELPFUL INFORMATION


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

DOWNLOAD

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

DOWNLOAD

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

DOWNLOAD

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ALEXANDER FORBES

http://www.afhealth.co.za/AFHealth%20Client%20Newsletters%20%20Email/HealthZMag/benefitsofvitality.pdf

http://www.afhealth.co.za/AFHealth%20Client%20Newsletters%20%20Email/HealthZMag/memberletter.pdf

http://www.afhealth.co.za/AFHealth%20Client%20Newsletters%20%20Email/HealthZMag/OptionchangeForm.pdf

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

Download the Discovery app on your smartphone

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

Head office – SandtonAlexander Forbes, 115 West Street, SandownPO Box 787240, Sandown, 2146Telephone (SA): 011 269 2690Telephone (International): +27 11 269 2690Fax (SA): 011 263 2397Fax (International): +27 11 263 2397email: [email protected] web: www.alexanderforbes.co.za

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

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

Stellenbosch40 Dorp Street, StellenboschPO Box 501, Stellenbosch, 7599Telephone (SA): 021 809 3777Telephone (International): +27 21 809 3777Fax (SA): 021 886 4432Fax (International): +27 21 886 4432email: [email protected]

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

Port Elizabeth256 Cape Road, Newton Park,Port ElizabethPO Box 27972, Greenacres, 6057Telephone (SA): 041 392 8300Telephone (International): +27 41 392 8300Fax (SA): 041 392 8543Fax (International): +27 41 392 8543

East London1st Floor Short Mill House, Quarry Office Park, Berea, East LondonPO Box 19367, Tecoma, 5214Telephone (SA): 043 701 4800Telephone (International): +27 43 701 4800Fax (SA): 043 721 0028Fax (International): +27 43 721 0028

Bloemfontein8-10 Reid Street, Westdene,BloemfonteinPO Box 12731, Brandhof, 9324Telephone (SA): 051 403 6500Telephone (International): +27 51 403 6500Fax (SA): 011 669 2952Fax (International): +27 11 669 2952

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Alexander Forbes Health Digimag

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