DISCOVERY HEALTH MEDICAL SCHEME CHANGES FOR 2013

Transcription

1 Dear Alexander Forbes Client November 2012 DISCOVERY HEALTH MEDICAL SCHEME CHANGES FOR 2013 Discovery Health recently made their 2013 benefits and contributions available. You are provided the opportunity to change your plan option with effect from 1 January You need to consider your healthcare requirements for the following year and decide if you have the right level of cover. You are under no obligation to make a change but if you want to amend your current plan option, you need to submit your new plan option information to Discovery Health before the cut off date of 14 December If you are part of an employer group your deadline and process might be different from this, please confirm this with your payroll department. Discovery Health Medical Scheme will send you a brochure containing a detailed summary of the 2013 benefits and rates after carefully studying the changes for 2013 you will need to decide whether you wish change your plan option. This letter gives you details on the following highlights: CONTRIBUTION INCREASE Discovery Health announced a 10.9% average weighted increase for 2013 NEW BENEFIT PLANS Find out about a new Keycare and Comprehensive plan for 2013 HOSPITALISATION CHANGES Changes to deductibles and copayments. CHRONIC MEDICINE CHANGES Formulary changes and new medicines on the Executive plan KEYCARE BENEFIT CHANGES Changes to income bands and contributions VITALITY CHANGES Introduction of new HealthyFood and mobile provider. CHANGING YOUR PLAN You have until the cut off date to change your plan make sure you know what to do. NEED ASSISTANCE? Who to call for information, advice and questions. DAY TO DAY BENEFIT CHANGES New benefits and other changes on the Insured Network Benefit

2 CONTRIBUTION INCREASE The overall weighted average contribution increase, effective 1 January 2013, of 10.9% reflects a view of the current industry scenario and the Scheme s operating position. The increases by benefit plan are explained in the table below. Increase percentage 11.8% Increase percentage 9.8% Executive Saver Comprehensive Classic Saver Classic Comprehensive Classic Delta Saver Classic Delta Comprehensive Essential Saver Essential Comprehensive Essential Delta Saver Essential Delta Comprehensive Priority Core Classic Core Classic Priority Classic Delta Core Essential Priority Essential Core Essential Delta Core Saver Coastal Saver Key Care Key Care Plus R Core Key Care Core Coastal Core Please refer to Annexure A for the 2013 contributions and the increased threshold levels on the Priority, Comprehensive and Executive plan options. NEW BENEFIT PLANS Classic Comprehensive Zero MSA This benefit plan offers you the same risk benefits as the Classic Comprehensive benefit plan. The plan does not have a Medical Savings Account an Insured Network Benefit or Trauma Recovery Extender Benefit. MRI and CT scans are covered when the threshold is reached. The plan may be suitable for members who require a Comprehensive plan to access the additional chronic medicine cover but do not require excessive day-to-day cover or for members who prefer to fund their day to day expenses from their own pocket. KeyCare Access This benefit plan offers members unlimited cover for emergencies, accidental trauma, childbirth and care of newborn babies up to 12 months after birth in private network hospitals. Cover for planned procedures are available at state facilities. Benefits for GPs, optometry and dentistry will be covered in the same way as KeyCare Plus. Private specialist consultations will be covered for maternity, trauma and emergencies up to the limit of R2 550 per person. Contributions are calculated on monthly income and ranges from R450 to R1 300 for a principal member. HOSPITALISATION BENEFITS Networks Refer to Annexure C for the list of hospitals applicable to the KeyCare and Delta plan options.

3 Deductibles Members participating on Priority plans should note that the defined deductibles for in-hospital procedures will range from R1 950 to R9 500 in Please refer to Annexure B for more details. Members participating on Delta plans should note that the deductible has increased to R5 000 per planned hospital admission if you do not make use of the Delta network of hospitals (Refer to Annexure C). The 2013 deductibles for in-hospital dentistry are as follows: Category of members In-hospital treatment Treatment in day clinic Members younger than 13 R1 450 R700 Members older than 13 R3 650 R2 400 All routine, conservative dentistry, such as preventative treatments, simple fillings and root canal treatments will be covered from your available day to day benefits from 1 January CHRONIC MEDICATION You have cover for a list of chronic conditions as per your plan choice and cover for approved medicine on Discovery Health s medicine list. If you take medicine that falls outside of Discovery Health s medicine list, there is a set monthly amount available to cover medicine costs. KeyCare members are limited to the formulary and do not have access to the monthly amount. Discovery Health will pay medicine up to the Discovery Health Medicine Rate. Chronic conditions need to be approved by Discovery Health for the condition to be covered from the Chronic Illness Benefit. When you use MedXpress, Discovery s medicine delivery service, you will not be required to fund any delivery or administration fees. Discovery s qualified service agents can also advise you on the most cost-effective alternatives and you will be charged at the Discovery Health Medicine Rate or less minimising co-payments. All major pharmacy chains, including Clicks, Dis-Chem and MediRite and more than community pharmacies are contracted to charge Discovery Health members at this rate. Discovery Health made three key enhancements to the Chronic Illness Benefit. ChroniCare Extended chronic medicine Members registered for hypertension, hyperlipidemia, diabetes or asthma will benefit from the new partnership between Discovery Health and Dischem pharmacies. Members will qualify for up to 25% cash back on certain products bought from Dischem stores country wide. To activate the ChroniCare benefit you must register on the Discovery Health website. You will automatically qualify for 10% cash back. The cash back will increase to 25% on completion of the Vitality Health Check. Monitoring devices, speciality foods, health education, routine wellness tests, footwear and accessories, fitness and wellbeing items will qualify for cash back at Dischem. Discovery will provide cover for the following list of 10 additional branded medicines for EXECUTIVE BENEFIT PLAN members. LivingVitality Members will be empowered to manage and understand their chronic conditions using experts, tools and social media. Discovery s list of chronic medicine will be reviewed based on annual pricing movements. Changes will be implemented from 1 July 2013 giving members the opportunity to discuss this with their medical practitioner.

4 DAY-TO-DAY BENEFITS Members participating on Core plans do not have access to day-to-day benefits. Except for the KeyCare Plus and KeyCare Access plan options, which offer limited benefits through network providers, all other plan options provide day to day cover through the Medical Savings Account and Above Threshold Benefit. The Above Threshold Benefit is applicable to Priority, Comprehensive and the Executive plan. Day to day benefits Optometry Allied, Therapeutic and Psychology Extender Benefit Members will qualify for an upfront 20% discount on frames and lenses through the new network of optometrists. Chiropractors have been added to the Allied and Therapeutic and Psychology Extender Benefit. The Oncology, hip and knee joint prosthesis and Specialised Medicine and Technology Benefit limits have not been increased. Insured Network Benefit Members who have depleted their annual Medical Savings Account can enjoy cover through the Insured Network Benefit when using providers in the Discovery Network (not available on KeyCare Plans). Members will be covered as follows: Benefit Plan GP consultations Pathology Medication (generic) as from 1 January 2013 Description Executive Plan Classic Comprehensive Classic Delta Comprehensive Classic Comprehensive Zero MSA Essential Comprehensive Essential Delta Comprehensive Classic Priority Essential Priority Classic Saver Classic Delta Saver Essential Saver Essential Delta Saver Coastal Saver Consultation costs covered by medical scheme in full within DH network of GP providers To access the pathology cover from 1 January 2013, tests should be done at Clicks, Dischem and Medi+Rite Schedule 3 + acute generic medication will be covered while members are in their Self Payment Gaps (SPG). The benefit is only available through Discovery Med Xpress, Clicks, Dischem, Medi+Rite and a network of independent pharmacies Unlimited benefit Unlimited benefit Unlimited benefit No benefit Unlimited benefit Number of consultations covered: Classic & Coastal plans Single member: 3 Family: 6 Essential plan Single member: 2 Family: 4 No benefit Unlimited benefit No benefit No benefit

5 KEYCARE CHANGES Discovery Health has removed the lowest income band (R0 R3 900) and increased the child dependant rate on the income band R0 R6 250 significantly. A new KeyCare plan has been introduced, i.e. KeyCare Access. Herewith a summary of the KeyCare series of plans. Critical care Emergencies and trauma Planned Procedures Child birth and care of newborns Other in-hospital procedures PLUS ACCESS (NEW) CORE KeyCare Network KeyCare Network KeyCare Network of Hospitals of Hospitals of Hospitals KeyCare Access Hospital Network KeyCare Hospital State facilities KeyCare Hospital Network or day Network or day surgery network surgery network Yes Yes Yes Chronic illness Benefit 26 Prescribed Minimum Conditions Day-to-day primary medical care Unlimited cover for GP consultations, blood tests, x-rays, medicine within network of providers Screening and prevention Yes Yes Yes Specialist Consultations Yes Yes* No Yes Yes Cover for antenatal services and specialist consultations only *The KeyCare Access Plan covers specialist visits in the KeyCare Access hospital network for maternity (refer to Annexure C), care for babies up to 12 months after birth, trauma and emergencies up to a limit. For all other healthcare services Discovery Health cover specialists employed by a state facility. VITALITY AND KEYFIT BENEFIT Enhancements to Vitality Extending the HealthyFood benefit Pick n Pay and Woolworths Technology-driven wellness engagement VitalityMobile enabling a wellness Community in partnership with Cell C HealthyFood Benefit To complement the HealthyFood benefit at Pick n Pay, Woolworths has joined as a partner for members on the Executive and Classic benefit plans, excluding Classic Core. Members can choose between Pick n Pay and Woolworths to get up to 25% cash back, subject to each adult dependant completing an onlinevitality Health Review. Members will still qualify for a 10% cash back when shopping at the other partner. LivingVitality: Track, improve and engage for better health and fitness Members can track their fitness and earn Vitality points, using a range of new devices, including Garmin, Polar, adidas micoach and even their cellphones. VitalityMobile By connecting Vitality members through free calls and boosted data members will have access to top of the range phone brands through Cell C. For a fee of R29 a month members can call other VitalityMobile members at no extra charge. This benefit will not be available to all packages e.g. prepaid options. New DiscoveryCard Partners DiscoveryCard holders receive cash back from leading retailers in Discovery s partner store network. Builders Warehouse, Builders Express, Incredible Connection and Sunglass Hut will be added to the list of partner stores in 2013.

6 The Health Wallet The Health Wallet replaces the Medical Savings Booster from 1 January 2013 and can be activated on the DiscoveryCard for a yearly fee of R180. The Health Wallet enables members to pay for their day-to-day healthcare expenses by monthly debit order/lump sum deposit. Members can also switch their HealthyFood, HealthyCare, HealthyGear, MedSaver and ChroniCare cash back to pay into their Health Wallet to boost their health cover. Severe illness cover is included and the payout is based on severilty level and their Vitality status. CHANGING YOUR PLAN HOW TO CHANGE YOUR PLAN If you are part of an employer group please contact your HR Department on the processe to be followed should you wish to change your medical aid option. If you are not linked to an employer group you can change your medical aid option on line (provided you have registered with Discovery Health) or by contacting them on Please note that if you do not notify Discovery Health of your plan option prior to the deadline, you will remain on your current option and only be afforded another opportunity to change your option for January ASSISTANCE WITH CHOOSING YOUR PLAN OPTION Members may contact the Discovery Health Medical Scheme for general plan information by: Browsing the website or making use of the national walk-in centres. The Vitality magazine (Spring edition) will also provide valuable information. Alexander Forbes Health consultants will also be available to assist you to make the right plan option choice. Contact details are as follows: Health office Tel number address Discovery Health info@discovery.co.za Alexander Forbes - Sandton office hcclientservices@aforbes.co.za Alexander Forbes - Stellenbosch office clientspecialist@aforbes.co.za Finally, we wish you good health in 2013! Alexander Forbes Health Consultants and Actuaries Discovery Health Alexander Forbes Health - Stellenbosch Alexander Forbes Health - Sandton Tel: healthinfo@discovery.co.za Tel: clientspecialist@aforbes.co.za Tel: hcclientservices@aforbes.co.za Disclaimer: While all reasonable care has been taken by Alexander Forbes Health in compiling this communication, we have relied upon the accuracy and completeness of the information made available to us and subsequently cannot accept any liability or any errors or omissions that may arise as a result of the reliance of such information

7 ANNEXURE A - CONTRIBUTION TABLES TOTAL MONTHLY CONTRIBUTIONS Series Plan Principal Adult Child Member Dependant* Dependant * Executive Executive R3 764 R3 764 R714 Comprehensive Classic Comprehensive R3 086 R2 918 R616 Classic Delta Comprehensive R2 780 R2 629 R553 Classic Comprehensive Zero MSA R2 315 R2 189 R462 Essential Comprehensive R2 594 R2 451 R520 Essential Delta Comprehensive R2 335 R2 207 R467 Priority Classic Priority R2 069 R1 629 R828 Essential Priority R1 778 R1 397 R710 Saver Classic Saver R1 814 R1 428 R725 Classic Delta Saver R1 449 R1 141 R581 Essential Saver R1 442 R1 078 R576 Essential Delta Saver R1 152 R 864 R460 Coastal Saver R1 428 R1 070 R574 Core Classic Core R1 350 R1 062 R539 Classic Delta Core R1 081 R 849 R432 Essential Core R1 160 R 869 R464 Essential Delta Core R 927 R 695 R372 Coastal Core R 998 R 748 R398 KeyCare KeyCare Plus (R8 301+) R1 330 R1 330 R356 KeyCare Plus (R6 251 to R8 300) R 893 R 893 R250 KeyCare Plus (R0 to R6 250) R 638 R 638 R230 KeyCare Access (R8 301+) R1 300 R1 300 R350 KeyCare Access (R6 251 to R8 300) R 865 R 865 R245 KeyCare Access (R3 901 to R6 250) R 600 R 600 R215 KeyCare Access (R0 to R3 900) R 450 R 450 R195 KeyCare Core (R8 301+) R 982 R 982 R222 KeyCare Core (R6 251 to R8 300) R 636 R 636 R158 KeyCare Core (R0 to R6 250) R 511 R 511 R129 *Contributions are charged up to a maximum of 3 children; Dependants 21 years + are considered adult dependants. Medical Savings Account (included in the above monthly contribution, where applicable) Series Plan Principal Member Adult Dependant Child Dependant Annual Monthly Annual Monthly Annual Monthly Executive Executive R R941 R R941 R2 136 R178 Classic R R771 R R729 R1 848 R154 Comprehensive Classic Delta R R695 R R657 R1 656 R138 Essential R R389 R R367 R 936 R 78 Priority Saver Essential Delta R R350 R R331 R 840 R 70 Classic R R517 R R407 R2 484 R207 Essential R R266 R R209 R1 272 R106 Classic R R453 R R357 R2 172 R181 Classic Delta R R362 R R285 R1 740 R145 Essential R R216 R R161 R1 032 R 86 Essential Delta R R172 R R129 R 828 R 69 Coastal R R357 R R267 R1 716 R143

8 ANNEXURE A - CONTRIBUTION TABLES ANNUAL THRESHOLD LEVELS Executive & Comprehensive plans Executive Plan Comprehensive Plans Principal member R R Per adult R R Per child* R R * A maximum of three children are counted when calculating the Annual Threshold Priority plans Annual Threshold Above Threshold Limit Principal member R9 170 R7 800 Per adult R6 890 R5 550 Per child* R3 000 R2 680 * A maximum of three children are counted when calculating the Annual Threshold and Above Threshold Limit VITALITY & KEYFIT CONTRIBUTIONS Single Member Member with one dependant Vitality R155 R179 R199 KeyFIT R 33 R 39 R 49 Vitality & KeyFIT R165 R195 R229 LATE JOINER PENALTIES Member with two or more dependants 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 X contributions 5 14 years 0,25 X contributions years 0,5 X contributions 25+ years 0,75 X 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 creditable cover

9 ANNEXURE B PRIORITY SERIES (DEDUCTIBLES) Members need to pay an amount upfront to the hospital when the member is admitted for one of the following procedures: DEDUCTIBLE AMOUNT R 1950 R 2600 R4 700 R9 500 PROCEDURE Adenoidectomy Conservative back and neck treatment Myringotomy (grommets) Tonsillectomy Colonoscopy Cystoscopy Gastroscopy Proctoscopy Sigmoidoscopy Arthroscopy Endometrial ablation Functional Nasal Procedures Hysterectomy (except for pre-operatively diagnosed cancer) Hysteroscopy Laparoscopy Joint replacements Nissan fundoplication (reflux surgery) Spinal (back and neck) surgery 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 prior to the procedure to confirm their benefits.

10 ANNEXURE C DISCOVERY HEALTH HOSPITAL NETWORKS AREA HOSPITALS DELTA KEYCARE Core / Plus Access EASTERN CAPE East London Life Beacon Bay East London Life St James Operation theatres East London Life East London Private East London Life St Dominic s Private Humansdorp Life Isivivana Private Kokstad NetCare Kokstad Hospital Port Elizabeth Life New Mercantile Queenstown Life Queenstown Private Uitenhage Netcare Cuyler clinic Uitenhage Netcare uitenhage hospital Umtata Life St Mary's Private FREES TATE Bethlehem Hoogland MediClinic Bloemfontein Bloemfontein Eye Centre Bloemfontein Netcare Pelonomi Private Bloemfontein Life Rosepark Clinic Bloemfontein Life Pasteur Bloemfontein Netcare Universitas Private Welkom Ernest Oppenheimer Welkom Welkom Mediclinic Welkom St Helena hospital GAUTENG Alberton Clinton Clinic Bedfordview Life Bedford Gardens hospital Benoni Life The Glynwood Botshelong Empilweni-clinic (Clinix Boksburg Vosloorus) Boksburg Sunshine Centre Brakpan Life Dalview Clinic Fourways Life Fourways hospital Germiston Life Roseacres Clinic Heidelberg Life Suikerbosrand Clinic Johannesburg Netcare Rand Clinic Johannesburg Morningside Mediclinic Johannesburg Johannesburg Eye Clinic Johannesburg The Dondald Gordon Medical Centre Johannesburg Netcare Garden City Clinic Johannesburg Life Brenthurst Clinic Kempton park Arwyp Medical Centre Krugersdorp Netcare krugersdorp hospital Lakefield Netcare Optiklin Eye Lenasia Lenmed Clinic Midrand Life Carstenhof Clinic Pretoria Netcare Bougainville Private Pretoria Centurion Eye hospital Pretoria Netcare Femina hospital Pretoria Life Little Company of Mary Pretoria Life Eugene Marais Pretoria Netcare Jacaranda Pretoria Legae MediClinic Pretoria Louis Pasteur Pretoria Medforum MediClinic

11 ANNEXURE C DISCOVERY HEALTH HOSPITAL NETWORKS AREA HOSPITALS DELTA KEYCARE Core / Plus Access GAUTENG CONT. Pretoria Muellmed Pretoria Pretoria-Eye Institute Pretoria Zuid Afrikaans Randfontein Life Robinson Randfontein Sir Albert Medical Centre Roodepoort Life Wilgeheuwel hospital Sasolburg Netcare Vaalpark hospital Soweto Clinix Soweto (Tshepo Themba) Soweto Lesedi Clinic Springs Life Springs Parkland Clinic Springs Life St Mary s Women s Clinic Springs Netcare N!& hospital Thembisa Zamokuhle Private Vanderbijlpark Emfuleni MediClinic Vanderbijlpark Ocumed Vereeniging Clinix-Private, Sebokeng Vereeniging Midvaal Private Westgate Medgate Day Clinic KWAZULU-NATAL Amanzimtoti Netcare Kingsway hospital Chatsworth Life Chatsmed Garden Durban Life City Durban Life Entabeni Hospital Durban Ethekwini hospital Durban McCord Empangeni Life Empangeni Garden Clinic Isipingo Life Isipingo Clinic Kokstad Kokstad Private Ladysmith La Verna Newcastle Newcastle Private Phoenix Life Mount Edgecombe Pietermaritzburg Midlands Medical Centre Pietermaritzburg Netcare St Anne s Pinetown Life Crompton Port Shepstone Hibiscus Richards Bay Netcare The Bay Sydenham Nu Shifa Tongaat Victoria Private Westville Life Westville LESOTHO Lesotho Willie s hospital LIMPOPO Bela Bela St Vincent's Phalaborwa Clinix Phalaborwa Private Polokwane Limpopo MediClinic Thabazimbi Thabazimbi MediClinic Tzaneen Tzaneen MediClinic MPUMALANGA Barberton Barberton MediClinic Emalahleni/Witbank Life Cosmos Emalahleni/Witbank Emalahleni Day Ermelo Ermelo Private Middelburg Life Middelburg Private Nelspruit Nelspruit Private Trichardt Highveld MediClinic

12 AREA HOSPITALS DELTA KEYCARE Core / Plus Access NORTH WEST Carletonville Leslie Williams Private Carletonville Western Deep Clinic Klerksdorp Life Anncron Clinic Mafikeng Victoria Private Orkney West Vaal Clinic Potchefstroom Potchefstroom MediClinic Rustenburg Life Peglerae Rustenburg Netcare Ferncrest NORTHERN CAPE Kathu Kathu MediClinic Kimberley Kimberley MediClinic Upington Upington Private Vryburg Vryburg Private WESTERN CAPE Bellville Bellville Medical Centre Bellville Louis Leipoldt MediClinic Cape Town Netcare Christiaan Barnard Memorial Cape Town Netcare UCT Medical Centre Cape Town Cape Town Mediclinic Claremont Life Claremont hospital Claremont Life Kingsbury hospital Ceres Ceres Private Gatesville Gatesville Medical Centre George Geneva Clinic George George MediClinic Hermanus Hermanus MediClinic Kuilsriver Netcare Kuilsriver Private Milnerton Milnerton MediClinic Mitchells Plain Mitchells Plain Medical Centre Mossel Bay Bayview Oudtshoorn Cango Day clinic Oudtshoorn Klein Karoo MediClinic Paarl Paarl MediClinic Parow Panorama Mediclinic Somerset West Vergelegen Mediclinic West Coast Life West Coast Private Worcester Worcester MediClinic Please note that the list of hospitals is subject to change. You can go to for the latest list of hospitals. The list does not include the day clinics where members can get treatment without paying an amount upfront.