Critical hospital care Planned hospital care Chronic Illness Day-to-day medical care Screening and prevention discoverer s financial adviser publication Healthy equilibrium Managing the increasingly complex South African medical scheme environment requires achieving a balance between the opposing demands from multiple stakeholders. To achieve healthy growth and ongoing financial sustainability it is necessary to constantly enhance the quality of care, services and value that members receive. The principle of systemic equilibrium is fundamental to the effective management of a medical scheme. By implementing strategies which optimise the quality of our members care and the cost per unit of benefit, we have been able to consistently create positive shifts in the healthcare equilibrium point. Systemic equilibrium sys tem ic səˈstemik e qui lib ri um ˌēkwəˈlibrēəm; ˌekwə- A system is in equilibrium if every participant in the system is in the best possible position. The point at which this is reached is called the equilibrium point. Any structural change within a system creates a new equilibrium point satisfying the above criterion. A structural change is desirable if it generates a higher equilibrium point one where the aggregate position across all participants is improved. In health insurance the outcome for any participant can be defined as the ratio of the quality of care to the cost per unit of a benefit. A change within a health insurance system is positive to the system as a whole if it generates a positive change in the ratio of quality to cost. Quality\Cost Enhanced Oncology Delta plan range Corporate wellness Specialised Medicine and Technology Supplementary Cancer Protector Trauma Recovery Extender GP Network Overseas Treatment KeyFIT Payment arrangements KeyCare plan range R1 Funeral Plan HealthyFood Trauma Counselling Insured Network Medical Savings Booster Integrated Care Unit MedSaver 2012 Equilibrium point has focused on consistently raising the equilibrium point by enhancing the quality of care our members receive, controlling costs and improving their experience in the healthcare system. In 2012 we intend to accelerate this trajectory across the following key dimensions: Providing premium and benefit stability across the product range Bringing down the cost of healthcare for Discovery members Using the latest technologies to facilitate improvements in the quality of care Full Cover Choice: helping members navigate the healthcare system and minimise gaps in cover Using behavioural incentives to accelerate improvements in physical activity and preventive care HealthyCare HealthyCare HealthyGear Time 2012 8.9% increase across all plans Discovery Health MedSaver HealthyGear september :: 2011
Managing medical inflation Analysis of medical scheme cost drivers for 2011/2012 Medical scheme contribution increases are driven by healthcare provider inflation, changes in the demographic profile of the membership base and scheme-specific funding and solvency requirements. 1. The prices of medical goods and services Price inflation is the base cost driver of contribution increases and is determined by the tariffs that individual schemes negotiate with healthcare providers. Price inflation scale 2. Changes in the demographic profile and benefit utilisation For every year a medical scheme ages, claims costs increase by about 2% a year above price inflation. The rest of the industry has aged faster than. If this trend continues the difference in claims costs will accelerate. 35 34 33 32 31 Projected medical price inflation 0% 1% 2% 3% 4% 5% 6% 7% 8% 9% 10% 11% 12% Medicine price Consumer goods Industry average age progression Private healthcare sector staff salaries 3. Reserve funding and solvency requirements Margins for solvency and reserve funding are influenced by the need to fund higher reserves, to cover member claims and membership growth. Membership growth is important to the sustainability of a medical scheme in s case, new lives are on average seven years younger than the existing membership base and exhibit a 17% lower disease burden. However, for every new member joining a medical scheme, 25% of their yearly contributions must be added to reserves up front to meet the statutory solvency requirement. The rest of the open scheme market has struggled to grow membership, with most growth coming through mergers. Mergers are not a sustainable source of growth, as they are often accompanied by an increase in selective withdrawals and a deterioration in the scheme s demographic profile and claims experience. Discovery Bonitas Medihelp Medshield Momentum Fedhealth Liberty Bestmed Sizwe Keyhealth Membership growth: 2009 to 2010-40 000-20 000-20 000 40 000 60 000 80 000 100 000 120 000 30 Including mergers Excluding mergers 29 2005 2006 2007 2008 2009 2010 Source: Council for Medical Schemes annual report Rest of open schemes industry Source: Council for Medical Schemes annual report Advances in medical technology and treatment protocols also drive increased benefit utilisation and improved outcomes which impact all medical schemes and contribute an additional 1% 2% to contribution increases. Despite a 10% growth in membership, grew its member reserves year on year to almost R7 billion at the end of 2010. It has once again been awarded an AA+ rating as a reflection of its sound claims-paying ability. The 2011/2012 contribution increase The Medical Scheme s contribution increase of 8.9% for 2012 has been set to achieve the following key objectives: Maintain and enhance benefits in real terms Build member reserves in line with the Scheme s growth and solvency requirements Provide contribution stability with a uniform increase across all plans s inflationary contribution increase will ensure the Scheme maintains its significant pricing advantage over other open schemes in 2012. contribution increase Breakdown of increase Average open scheme market premium relative to R100 of premium R160 CPI + 6% CPI + 3% 8.9% Weighted average = 8.9% 9.8% R140 R120 R100 R80 Discovery contribution in 2012 R60 CPI 4.7% R40 R20 0 2008 2009 2010 2011 2012 Administration Managed care Provider tariffs Demographic and utilisation Reserve funding Low income Hospital Limited day-to-day Extensive day-to-day Average premium for other open schemes in 2011 Average premium for other open schemes in 2012 allowing for contribution increases between 7% and 13% Discoverer 02
MedSaver benefit Saving members 25% on over-the-counter medicine members spent R550 million on over-the-counter medicine in 2010. Through the MedSaver benefit, members have the potential to save more than R130 million by completing a Vitality Check and purchasing their over-the-counter medicine at Clicks. From January 2012, members will qualify for up to 25% cash back on all schedule 1 and 2 medicines purchased from any Clicks store countrywide. The MedSaver benefit in action Activate MedSaver Complete a Vitality Check Enjoy the rewards Visit a Clicks store Hello, Albert Log out» Health Heading A SubMenu Heading A Heading A Heading A Heading A Link the best of care in 2012 25% care The Discovery Life Income Continuation allows you to insure your monthly income, so you will have a replacement income to help you maintain your standard of living should you not be able to earn an income due to an injury or illness of yourself or a family member. In addition, the Overhead Expenses ensures your monthly business expenses are met under these conditions. 10% 25% Terms and Conditions Site Map Copyright 2012 Go to www.discovery.co.za to activate Members can complete a Vitality Check at a pharmacy in the Vitality Wellness Network or at a Wellness Day Purchase schedule 1 and 2 medicines Earn up to 25% cash back members most frequently purchased schedule 1 and 2 medicines Allergies Muscular pain Throat ailments Pain Coughs Cramps and spasms Skin conditions Colds and flu Technical details: 1 The MedSaver benefit is available to all members, subject to activation on www.discovery.co.za 2 Members do not need to swipe any card when purchasing their schedule 1 and 2 medicines to receive their MedSaver cash back. 3 The MedSaver cash back will be paid into the member s DiscoveryCard or any other nominated bank account every month. The minimum amount that will be paid to a member as a cash back is R50. If the accumulated cash back is less than R50, the payment will be held over until such time as the total accumulated cash back exceeds R50. 03 Discoverer
Full Cover Choice Helping members to navigate the healthcare system and maximise their cover Over the past five years, Discovery has made a significant investment in building structures in the healthcare system to improve our members cover. Through collaboration with healthcare providers, we have developed a series of benefit structures and payment agreements that offer our members greater certainty and reduce gaps in cover. Today, all Plans offer members the choice of being covered in full for hospitalisation and chronic medicine. In addition, members on Executive, Comprehensive and Priority Plans have access to full cover for GP consultations through the Insured Network. Full Cover Choice guides members to make decisions that will ensure that they do not experience any shortfalls in cover when the time comes to claim. Members should look out for the Full Cover Choice stamp in our communication to see when to use our range of online tools that will guide them to a Full Cover Choice. Hospital Advisor You are on the Classic Delta Core Plan Your hospital: Mount Edgecombe Hospital Your treating doctor: Dr. Smith Your procedure: Hip replacement This is not a Delta network hospital, you will need to pay R4 550. Find a Delta network hospital. Follow the Full Cover Choice stamp to find a hospital where you will be covered in full provides high cover ratios for in-hospital, chronic and oncology treatment across the plan range The key metric we use to measure the success of our benefit construct is the cover ratio, a measure of the level of cover a member has when engaging with the healthcare system. Importantly, our benefit design philosophy means that in areas of uncontrollable healthcare spend, such as hospitalisation, we are able to offer members the Full Cover Choice across the plan ranges. The key is ensuring that members are informed of the correct treatment choices to achieve full cover. In-hospital cover ratios (including medical specialists) Chronic cover ratios Oncology cover ratios 100% 100% 99.7% 98.1% 95.7% 94.1% 96.6% 91% 83% 95% 99% 96% Executive Classic Essential Coastal KeyCare Executive and Comprehensive Priority, Saver and Core KeyCare Executive and Comprehensive Priority, Saver, Core and KeyCare Discoverer 04
Online tools Helping members get the most out of their benefits We have developed a range of tools and advisors to help guide members through the healthcare system and to identify when they can make full cover choices. Hospital Advisor Going to hospital Hospital Advisor You are on the Classic Delta Core Plan Calculates whether a member can expect full cover for the hospital and medical This is not a Delta network hospital, you will need to pay R4 550. Find a Delta network hospital. Your hospital: Morningside Medi-clinic Your treating doctor: Dr. Smith specialists he or she has chosen. We pay up to R33 000 if you don t use a preferred supplier. We cover you in full if you do. Your procedure: Hip replacement We ll cover in full, based on your choices Visiting the doctor Allows for a member to locate a healthcare professional who has an agreement MaPS Advisor with. These healthcare professionals have agreed to charge the Rate for consultations and their claims will be covered in full. Provides information on how a member is covered for medicine, devices and medical equipment. The Med Advisor guides members to full cover choices by showing which medicines are on our medicine list and helping members to find a pharmacy in our network where they can avoid shortfalls in dispensing fees. Discovery Claims Med Advisor Yoir medicine: Drug A Buying medicine Med Advisor Advisor Provider: Med Xpress Store this medicine Use a generic medicine and Xpress for your approved chronic medicine and we ll cover it in full. New search Find a network pharmacy Discovery Claims Advisor The Advisor allows a member to better manage their day-to-day healthcare costs by showing, in real time, how close he or she is to reaching their day-to-day limits. Day-to-day medical expenses Classic Comprehensive SPG Prescribed medicine Optometry R9 300 R8 280 Advisor MSA ATB You are here R10 000 Allied and Therapeutic Healthcare Services You are here R16 900 Prescribe medicine The full complement of Advisor tools will be made available through a phased roll out in 2012. HospitalXpress A seamless hospital journey for Discovery members Going to hospital can be a stressful experience. Discovery s HospitalXpress makes admission to hospital convenient and seamless. This service offers express pre-admissions and online tools to authorise admissions, and confirm cover. HospitalXpress also connects members to select partners, bringing them a range of value-added services at reduced prices. Online authorisations and Hospital Advisor Hospital Advisor Your hospital: Mount Edgecombe Hospital Hospital pre-admission Online authorisation You are on the Classic Delta Core Plan Online express pre-admission This is not a Delta network hospital, you will need to pay R4 550. Find a Delta network hospital. Your treating doctor: Dr. Smith Your procedure: Hip replacement Your hospital: Choose your hospital Your hospital: Choose your hospital Your healthcare professional: Choose your professional When is your admission: Date When is your admission? Select date Find a healthcare professional in our network Book additional services + Follow the full cover choice stamp to find a hospital where you will be covered in full Patient information Value-added services Event summary We connect you to select partners for a range of concierge services to make your hospital stay more comfortable A summary of your hospital claim Point-to-point transfers Portable DVD entertainment Internet connectivity Personal grooming Your total hospital bill: R37 500 Shortfall (Click here to find out more) Paid by Discovery (Click here to find out more) We send members information leaflets about their hospital procedures. Discovery HospitalXpress is part of the Discovery Xpress range of services, which also includes: MedXpress Convenient medicine delivery service PracticeXpress ipad enabled suite of tools to improve the quality of care for Discovery members AdviserXpress Tools and information for financial advisers 05 Discoverer
PracticeXpress Using the latest technology to facilitate a step change in the quality of care and members experience of the healthcare system As the largest funder of care in South Africa, is uniquely positioned at the centre of the healthcare system. Through our engagement with members, healthcare professionals and corporate providers we are the largest health information carrier in the industry. By combining the significant set of data built up by caring for more than 2.5 million lives with the latest mobile tablet technology through the Apple ipad, PracticeXpress is set to change the face of healthcare in South Africa. The core functionality of PracticeXpress provides a suite of tools which will: 1. Enhance the quality of care for members by providing doctors with an integrated view of a patient s medical history 2. Reduce the administrative burden on members and doctors by allowing for a seamless co-ordination of downstream care through online referrals, scripting and chronic applications 3. Minimise the risk of co-payments by providing details of a member s plan coverage and the ability to search for and prescribe medicines covered on a member s plan option. Access data and details of previous doctor and hospital visits and previously prescribed medicines Access self-reported health measures such as body mass index and blood pressure Register for a new Chronic Illness and complete the necessary clinical entry criteria Add or change medicines and find cost-effective alternatives PracticeXpress highlights the Full Cover Choice when prescribing medicine, and shows the medicine formulary Refer a patient to another healthcare professional by submitting a clinically detailed report using the patient referral tool on PracticeXpress Referral information is stored for each patient and a record of all referrals is summarised on PracticeXpress Discoverer 06
Prescribe medicine for chronic and acute conditions directly from PracticeXpress Full cover is assured when prescribing medicine from the formulary Email scripts directly to MedXpress, s convenient, cost saving direct medicine delivery service Allows for the doctor to view details on the member s health plan coverage Members need to give consent to access medical records This can be done in real time by signing on the ipad screen PracticeXpress will be introduced to about 3 000 doctors nationwide from the first quarter of 2012 07 Discoverer
Targeted benefit enhancements in 2012 Over the past five years has enhanced benefits across each key component of members healthcare expenditure, resulting in broader access to expensive medical treatment, greater certainty of cover for members and a more efficient benefit design. benefit enhancements have focused on all key benefit areas over the past decade, representing over 80% of members healthcare spend Timeline Before 2006 2006-2011 2012 0% 10% 20% 30% 40% 50% 60% 70% 80% 90% Percentage of members healthcare spend 26% 6% 37% 4% 5% 6% Cumulative percentage of healthcare spend addressed through benefit enhancements Full cover for hospital account through negotiated tariffs Enhance flexibility and breadth of chronic cover Payment agreements and networks to minimise gaps in cover Access to the latest treatments and medicines Dental benefits Allied and Therapeutic Proprietary formulary and Chronic Drug Amount Specialist agreements: 88% coverage GP network: 87% coverage Unlimited cover for oncology treatment; over 99% coverage Simplified and enhanced dental benefit Enhanced cover Simplified benefit structure The 2012 Allied and Therapeutic We have redesigned the allied health benefits on the Executive, Comprehensive and Priority plans to: 1. Enhanced cover for nursing and psychiatry treatments 2. Offer more flexible cover across different medical disciplines 3. Provide unlimited cover for serious conditions An overview of changes to cover for allied health professionals Health professional Psychiatrists Registered counsellors Psychometrists Educational psychologists Clinical psychologists Stoma sister Wound care sister Registered nursing sister Chiropractors Homeopaths Podiatrists Speech therapists Occupational therapists Physiotherapists 2011 benefit 2012 benefit Covered as a specialist out-patient consultation, with no sub-limit Mental health benefit: R12 000 to R16 000 Home nursing benefit: R6 650 a family Covered through the Above Threshold with no sub-limits Cover provided through the Allied and Therapeutic : Executive Comprehensive Priority Classic Essential Classic Essential M R 12 500 R 10 000 R 6 000 R 6 000 R 4 000 M+ 1 R 15 000 R 13 500 R 8 500 R 8 500 R 6 000 M+ 2 R 17 500 R 16 500 R 11 000 R 11 000 R 7 500 M+ 3 R 21 000 R 19 000 R 13 000 R 13 000 R 9 000 Note: These changes do not apply to the Saver, Core and KeyCare series of plans. The Allied and Therapeutic Extender The Allied and Therapeutic Extender has been introduced to cater for members with severe, complex conditions who require short-term or long-term assistance from allied healthcare professionals. Less than 5% of members are expected to exceed the benefits available through the Allied and Therapeutic. For those who do exceed their benefits, the Allied and Therapeutic Extender will provide unlimited cover for a list of allied healthcare services, including physiotherapy, to members who meet the clinical entry criteria. Discoverer 10
Technical benefit changes for 2012 Updates to limits, co-payments, deductibles and thresholds Review of adult dependant eligibility criteria Medicine Rate Most benefit limits will increase in line with the contribution increase of 8.9%. Limits for internal prostheses, prescribed medicine and the oncology thresholds will remain the same, as the usage of these benefits have remained within current benefit thresholds. The limits for external medical appliances and devices will increase by surgical inflation. Annual thresholds will increase by between 8.6 and 10.1%. The intention of the adult dependant contribution is to provide the family unit with cover at an appropriate and affordable rate. We have recently noticed an increase in the number of dependants joining health plans as adult dependants at this discounted contribution. This creates an unfair advantage as these dependants gain access to cover at rates not available to members who are unable to join the Scheme in this way. To ensure that there is fair and consistent application of the adult dependant rate, and to minimise the risk to the Scheme, we will be implementing an adult dependant eligibility verification process for other family members. They may remain on the policy of the principal member but should they not fulfil the eligibility requirements they will no longer be eligible for the adult dependant rate, unless they are considered spouses, ex-spouses, full-time students up to the age of 25 or disabled. The Medicine Rate (DHMR) for 2012 is defined as the Single Exit Price (SEP) plus a dispensing fee of 26% of the SEP, up to a maximum of R26. All major pharmacy chains, including Clicks, Dis-Chem and MediRite, as well as over 1 200 community pharmacies are contracted to charge members at this rate. KeyCare Hospital Network changes The KeyCare Hospital Network is a dynamic national network of private hospitals and day clinics. We evaluate these facilities regularly against a set of criteria to ensure ongoing efficiency and quality of care. Our latest review has resulted in the removal of Moot Hospital from the network and the addition of Clinix Phalaborwa Private Hospital. Extending the KeyCare Day Surgery list of procedures In 2011, we introduced a network of day-case facilities through which members have access to full cover for a defined list of minor procedures. In 2012, we will expand the list to include additional planned procedures which may be safely performed in a day-case facility. Members will be guided to these facilities by their chosen GP or approved specialist. KeyCare changes for 2012 List of additional procedures that will be fully covered through the KeyCare Day Surgery Network General surgery Simple abdominal hernia repair ENT Nasal plugging for nose bleeds, nasal cautery Urology Vasectomy, prostate biopsy Orthopaedics Arthrocentesis, removal of pins and plates Gynaecology Hysteroscopy, diagnostic D&C, vulva/cone biopsy, cautery of vulva warts, treatment of Bartholins cyst/gland Cataract surgery Removal of cataracts Changes to the KeyCare Casualty We have simplified the KeyCare Casualty for 2012. Members will now have increased access to all casualty units that are located within a KeyCare network hospital. They will be charged a single, flat amount of R185 regardless of the KeyCare hospital they visit, rather than facing the uncertainty of variable deductibles for preferred and non-preferred casualty units. KeyCare exclusions The list of exclusions applicable to KeyCare plans will now include arthroscopy and the removal of varicose veins and bunions in 2012. Foundation Core Plan The Foundation Core Plan has not been actively marketed since 2004 and now houses fewer than 800 principal members. This plan will be closed from 2012. Current Foundation Core members will receive communications advising them of alternative plan options best suited to their needs. 11 Discoverer
A summary of Plans Executive Plan Classic Comprehensive Essential Comprehensive Classic Priority Essential Priority Summary The Executive Plan has the most extensive cover in hospital, for day-to-day healthcare and for emergencies, comprehensive chronic illness benefits and access to funding for the latest medical technology. Members have private ward cover of up to R1 150 a day. Members also have access to the Trauma Recovery Extender. The plans in the Comprehensive Series offer extensive in-hospital cover, as well as comprehensive day-to-day benefits, chronic illness benefits, access to funding for the latest medical technology and a Medical Savings Account with an Above Threshold. The Delta network options are an affordable alternative. It pivots on the Delta Hospital Network, where cover is provided in full, while also offering a choice of providers, subject to a deductible. The plans in the Priority Series offer extensive in-hospital cover and day-to-day benefits, through the Medical Savings Account and limited Above Threshold. Members also have cover for approved chronic medicine and access to the Trauma Recovery Extender. Hospital (procedures must be confirmed with ) Covers the hospital account from the Hospital and related accounts, eg specialists and radiology, from the Medical Savings Account and Above Threshold. Provides full cover if members use a specialist participating in a payment arrangement. We cover other specialists up to 300% of the Rate. We cover radiology, pathology, GPs and other healthcare services up to 100% of the Rate. Provides full cover if members use a specialist who participates in a payment arrangement, subject to available benefits. We cover other specialists up to 200% of the Rate. We cover radiology and pathology up to 100% of the Rate. We cover other healthcare professionals up to 100% of the Rate. Provides full cover if members use a specialist who participates in a payment arrangement, subject to available benefits. We cover other specialists up to 200% of the Rate. We cover radiology and pathology up to 100% of the Rate. We cover other healthcare professionals up to 100% of the Rate. Deductibles No deductibles For Delta network options only: Full cover at hospitals in the Delta Hospital Network. For planned hospital admissions at any other hospital, members must pay a R4 550 deductible. Members need to pay R1 750 to R8 600 upfront to the hospital when they are admitted for a defined list of procedures. Oncology DiscoveryCare s Oncology Programme covers the first R400 000 of members approved cancer treatment over a 12-month cycle. Cover is unlimited once cancer treatment costs go over this amount, but members need to pay 20% of the costs of all further treatment from their pocket. The member is also responsible for a co-payment if the provider charges more than the Rate. DiscoveryCare s Oncology Programme covers the first R400 000 of members approved cancer treatment over a 12-month cycle. Cover is unlimited once cancer treatment costs go over this amount, but members need to pay 20% of the costs of all further treatment from their pocket. The member is also responsible for a co-payment if the provider charges more than the Rate. DiscoveryCare s Oncology Programme covers the first R200 000 of members approved cancer treatment over a 12-month cycle. Cover is unlimited once cancer treatment costs go over this amount, but members need to pay 20% of the costs of all further treatment from their pocket. The member is also responsible for a co-payment if the provider charges more than the Rate. Chronic Illness Members have extensive and flexible cover for a list of chronic conditions. They have full cover for approved medicine on s medicine list or up to a set monthly amount for medicine not on our list. The Executive Plan has a more extensive medicine list and higher monthly medicine amounts than other plans. Members have extensive and flexible cover for a list of chronic conditions. They have full cover for approved medicine on s medicine list or up to a set monthly amount for medicine not on our list. The Comprehensive Plans have a more extensive medicine list and higher monthly medicine amounts than other plans. Members have cover for a list of chronic conditions. They have full cover for approved medicine on s medicine list or up to a set monthly amount for medicine not on our list. Day-to-day benefits Funded from the Medical Savings Account or from the Above Threshold once medical expenses have reached the Annual Threshold. We further extend members day-to-day cover through the Insured Network by paying for the following when they have spent their annual Medical Savings Account deposit: We cover the full cost of members consultation fees if they go to a GP in our network. We pay the claim directly to the GP. We cover blood tests at our network providers if members GPs or specialists request the appropriate tests using the pathology form (available on our website). The Allied and Therapeutic Extender gives unlimited cover for a list of allied healthcare services if members have reached the Allied and Therapeutic limit. The unlimited cover depends on the condition and criteria for it. Funded from the Medical Savings Account or from the Above Threshold once day-to-day expenses have reached the Annual Threshold. We further extend members day-to-day cover through the Insured Network by paying for the following when they have spent their annual Medical Savings Account deposit: We cover the full cost of members consultation fees if they go to a GP in our network. We pay the claim directly to the GP. We cover blood tests at our network providers if members GPs or specialists request the appropriate tests using the pathology form (available on our website). The Allied and Therapeutic Extender gives unlimited cover for a list of allied healthcare services if members have reached the Allied and Therapeutic limit. The unlimited cover depends on the condition and criteria for it. Funded from the Medical Savings Account or from the limited Above Threshold once day-to-day expenses have reached the Annual Threshold. The Above Threshold has an overall annual limit. We pay all day-to-day benefits up to the overall Above Threshold limit or the amounts of benefits available, whichever applies first. We further extend members day-to-day cover through the Insured Network by paying for the following when they have spent their annual Medical Savings Account deposit: We cover the full cost of members consultation fees if they go to a GP in our network. We pay the claim directly to the GP. We cover blood tests at our network providers if members GPs or specialists request the appropriate tests using the Discovery Health pathology form (available on our website). Trauma Recovery Extender We cover certain out-of-hospital claims for members recovery after certain traumatic events from the Trauma Recovery Extender. This cover applies for the rest of the year in which the trauma took place, as well as the year after the trauma. We cover certain out-of-hospital claims for members recovery after certain traumatic events from the Trauma Recovery Extender. This cover applies for the rest of the year in which the trauma took place, as well as the year after the trauma. We cover certain out-of-hospital claims for members recovery after certain traumatic events from the Trauma Recovery Extender. This cover applies for the rest of the year in which the trauma took place, as well as the year after the trauma. Above Threshold The Above Threshold is unlimited. The Above Threshold is unlimited. The Above Threshold is limited. MRI and CT scans We pay the hospital account from members Hospital and all related accounts from their Medical Savings Account or Above Threshold if the scan is done during an approved admission. We pay MRI or CT scans up to 100% of the Rate. If members are in hospital as part of an approved hospital admission, we cover their MRI or CT scan up to 100% of the Rate from their Hospital. If they are admitted for conservative neck or back treatment, we pay the first R2 300 of the scan code from their day-to-day benefits. We pay the balance from their Hospital, up to 100% of the Discovery Health Rate. If members MRI or CT scan is done as part of an approved hospital admission, we cover their MRI or CT scan up to 100% of the Discovery Health Rate from their Hospital. If they are admitted for conservative neck or back treatment, they need to pay the first R1 750 of the hospital account, and the first R2 300 of the scan code is paid from their day-to-day benefits. We pay the balance from their Hospital, up to 100% of the Discovery Health Rate. Dentistry There is an overall limit of R30 500 for each person. We pay the hospital account from the Hospital. We pay all related accounts from the Medical Savings Account and Above Threshold. Members need to pay a deductible upfront for dental admissions. We pay the related accounts from the Hospital, up to 100% of the Rate. All dental appliances, their placement and orthodontic treatments (including orthognathic surgery) are paid at 100% of the Rate from members day-to-day benefits, up to an annual limit of R17 400 a person. Members need to pay a deductible upfront for dental admissions. We pay the related accounts from the Hospital, up to 100% of the Rate. All dental appliances, their placement and orthodontic treatments (including orthognathic surgery) are paid at 100% of the Discovery Health Rate from members day-to-day benefits, up to an annual limit of R10 850 a person. The overall Above Threshold limit applies. Contributions Executive Plan Classic Comprehensive Essential Comprehensive Classic Priority Essential Priority Classic Delta Essential Delta Main member R3 365 R2 760 R2 485 R2 320 R2 088 R1 850 R1 590 Adult dependant R3 365 R2 609 R2 350 R2 191 R1 972 R1 457 R1 249 Child* R638 R552 R494 R463 R417 R740 R635 * We count a maximum of three children when we work out the monthly contribution. If an adult dependant does not meet our eligibility criteria we will charge the same contribution as the main member s contribution. This is only a summary of the key benefits and features of the Medical Scheme Plans, pending formal approval from the Council for Medical Schemes. Full details can be found in the Scheme Rules. For a copy of the rules, email compliance@discovery.co.za. Medical Scheme, registration number 1125, is administered by (Pty) Ltd, registration number 1997/013480/07, an authorised financial services provider. Discoverer 12
Classic Saver Essential Saver Coastal Saver Classic Core Essential Core Coastal Core KeyCare Plus KeyCare Core Summary The plans in the Saver Series offer a high level of in-hospital cover and a Medical Savings Account for day-to-day medical expenses. Members also have cover for approved chronic medicine and access to the Trauma Recovery Extender. The Delta network options are an affordable alternative. They pivot on the Delta Hospital Network, where cover is provided in full, while also offering a choice of providers, subject to a deductible. The plans in the Core Series offer a high level of in-hospital cover. Members also have cover for approved chronic medicine. The Delta network options are an affordable alternative. It pivots on the Delta Hospital Network, where cover is provided in full, while also offering a choice of providers, subject to a deductible. The plans in the KeyCare Series provide cost-effective cover for the low-income market. The KeyCare Series pivots on a network of hospitals and primary care doctors. KeyCare Plus members also have access to the Trauma Recovery Extender. Hospital (procedures must be authorised by ) Provides full cover if members use a specialist who participates in a payment arrangement. We cover other specialists up to 200% of the Discovery Health Rate. We cover radiology and pathology up to 100% of the Discovery Health Rate. We cover other healthcare professionals up to 100% of the Rate. Covers procedures and consultations in a network of coastal hospitals in full if members use a specialist who participates in a payment arrangement, or up to 100% of the Rate if not. Members are liable for 30% of the hospital account if they choose to go outside the network of coastal hospitals for an elective procedure. Provides full cover if the member uses a specialist who participates in a payment arrangement. We cover other specialists up to 200% of the Rate. We cover radiology and pathology up to 100% of the Rate. We cover other healthcare professionals up to 100% of the Rate. Covers procedures and consultations in a network of coastal hospitals in full if members use a specialist who participates in a payment arrangement, or up to 100% of the Rate. Members are liable for 30% of the hospital account if they choose to go outside the network of coastal hospitals for an elective procedure. Covers medical expenses when members are admitted to hospital in the network of KeyCare hospitals. Provides full cover if they use a specialist who participates in the KeyCare payment arrangement. We cover other healthcare professionals up to 100% of the Discovery Health Rate. Deductibles For Delta network options only: Full cover at hospitals in the Delta Hospital Network. For planned hospital admissions at any other hospital, members must pay a R4 550 deductible. No deductibles For Delta network options only: Full cover at hospitals in the Delta Hospital Network. For planned hospital admissions at any other hospital, members must pay a R4 550 deductible. No deductibles If members go to one of our casualty units in the KeyCare network of hospitals, they pay the first R185 of the consultation. Members must call us to confirm their benefits before being admitted. No cover Oncology DiscoveryCare s Oncology Programme covers the first R200 000 of members approved cancer treatment over a 12-month cycle. Cover is unlimited once cancer treatment costs go over this amount, but members need to pay 20% of the costs of all further treatment from their pocket. DiscoveryCare s Oncology Programme covers the first R200 000 of members approved cancer treatment over a 12-month cycle. Cover is unlimited once their cancer treatment costs go over this amount, but members need to pay 20% of the costs of all further treatment from their pocket. We cover members cancer treatment if it is a Prescribed Minimum and if they go to a cancer specialist in our network. The member is also responsible for a co-payment if the provider charges more than the Rate. The member is also responsible for a co-payment if the provider charges more than the Rate. The member is also responsible for a co-payment if the provider charges more than the Rate. Chronic Illness Members have cover for a list of chronic conditions. Members have full cover for approved medicine on s medicine list or up to a set monthly amount for medicine not on our list. For Delta Network options, members must get their approved medicine from a network pharmacy. If they get their medicine anywhere else, they need to pay a 20% co-payment. Members have cover for a list of chronic conditions. Members have full cover for approved medicine on s medicine list or up to a set monthly amount for medicine not on our list. For Delta Network options, members must get their approved medicine from a network pharmacy. If they get their medicine anywhere else, they need tp pay a 20% co-payment. Members have cover for a list of chronic conditions as long as their medicine is on the KeyCare medicine list and they get their approved medicine from our network pharmacy or from their chosen GP. If they get their medicine anywhere else, they need to pay 20% of the Discovery Health Medicine Rate. Day-to-day benefits Funded from the Medical Savings Account. We extend members day-to-day cover through the Insured Network by paying for GP consultations if they go to a GP in our network if they have spent their annual Medical Savings Account deposit. The maximum number of consultations that we cover for a single member and a family each year depends on their plan type: Classic and Coastal plans: Single member: three consultations Family: six consultations Essential plan: Single member: two consultations Family: four consultations No day-to-day benefits available to Core Plan members. Offers access to day-to-day cover through the KeyCare network of GPs, dentists and optometrists. Radiology is covered at a network provider only. We cover wheelchairs, wheelchair batteries and cushions, transfer boards, mobile ramps, commodes, long-leg callipers, crutches and walkers on the KeyCare mobility list, from a network provider, up to a limit of R3 800 a family. No day-to-day benefits available to KeyCare Core members. Trauma Recovery Extender We cover certain out-of-hospital claims for members recovery after certain traumatic events from the Trauma Recovery Extender. This cover applies for the rest of the year in which the trauma took place, as well as the year after the trauma. The Trauma Recovery Extender is not available. We cover certain out-of-hospital claims for members recovery after certain traumatic events from the Trauma Recovery Extender. This cover applies for the rest of the year in which the trauma took place, as well as the year after the trauma. The Trauma Recovery Extender is not available. Above Threshold There is no Above Threshold. There is no Above Threshold. There is no Above Threshold. MRI and CT scans If members MRI or CT scans are done as part of an approved hospital admission, we pay it up to 100% of the Rate from their Hospital. If they are admitted for conservative back or neck treatment, we pay the first R2 300 of the scan code from their day-to-day benefits. We pay the balance from their Hospital up to 100% of the Rate. If members MRI or CT scans are done as part of an approved admission, we pay it from their Hospital. If they are admitted for conservative back or neck treatment or the scan is unrelated to their admission, we do not pay for it. If members scans are related to an approved hospital admission, we pay it from their Hospital. If it is not related to an approved hospital admission, we pay it from the Specialist, up to R2 300 for each person. We do not pay for MRI or CT scans that are related to conservative back or neck treatment. Dentistry Members need to pay a deductible upfront for dental admissions. We pay the related accounts from the Hospital, up to 100% of the Rate. All dental appliances, their placement and orthodontic treatment (including orthognathic surgery) are paid at 100% of the Discovery Health Rate from the members Medical Savings Account. Members need to pay a deductible upfront for dental admissions. We pay the related accounts from the Hospital, up to 100% of the Rate. The member needs to pay all dental appliances, their placement and orthodontic treatments (including orthognathic surgery). We cover selected basic dentistry (consultations, fillings and extractions) at a dentist in the KeyCare dentist network. No cover Contributions Classic Saver Essential Saver Coastal Saver Classic Core Essential Core Coastal Core KeyCare Plus KeyCare Core Classic Delta Essential Delta Classic Delta Essential Delta (R0- R3 900) (R3 901- R6 250) (R6 251- R8 300) (R8 301+) (R0- R6 250) (R6 251- R8 300) (R8 301+) Main member R 1 652 R1 320 R1 312 R1 049 R1 277 R1 229 R984 R1 056 R844 R892 R485 R581 R813 R1 211 R465 R579 R894 Adult dependant R1 300 R1 038 R982 R787 R957 R967 R773 R791 R633 R669 R485 R581 R813 R1 211 R465 R579 R894 Child* R660 R529 R524 R418 R513 R491 R393 R422 R339 R356 R129 R168 R228 R324 R117 R144 R202 * We count a maximum of three children when we work out the monthly contribution. If an adult dependant does not meet our eligibility criteria we will charge the same contribution as the main member s contribution. 13 Discoverer
contributions 2012 Series Plan Contributions Main member Adult Child* Contributions to Medical Savings Account Main member Total contributions Annual thresholds Executive Executive 2 524 2 524 479 841 841 159 3 365 3 365 638 10 090 10 090 1 900 Comprehensive Priority Saver Core KeyCare Adult Child* Main member Adult Child* Main member Classic Comprehensive 2 070 1 957 414 690 652 138 2 760 2 609 552 9 300 9 300 1 750 Classic Delta Comprehensive network option 1 864 1 763 371 621 587 123 2 485 2 350 494 9 300 9 300 1 750 Essential Comprehensive 1 972 1 863 394 348 328 69 2 320 2 191 463 9 300 9 300 1 750 Essential Delta Comprehensive network option 1 775 1 677 355 313 295 62 2 088 1 972 417 9 300 9 300 1 750 Classic Priority 1 388 1 093 555 462 364 185 1 850 1 457 740 8 200 6 150 2 690 Essential Priority 1 352 1 062 540 238 187 95 1 590 1 249 635 8 200 6 150 2 690 Classic Saver 1 239 975 495 413 325 165 1 652 1 300 660 No Annual Threshold Classic Delta Saver network option 990 779 397 330 259 132 1 320 1 038 529 No Annual Threshold Essential Saver 1 116 835 446 196 147 78 1 312 982 524 No Annual Threshold Essential Delta Saver network option 892 669 356 157 118 62 1 049 787 418 No Annual Threshold Coastal Saver 958 718 385 319 239 128 1 277 957 513 No Annual Threshold Classic Core 1 229 967 491 No Medical Savings Account 1 229 967 491 No Annual Threshold Classic Delta Core network option 984 773 393 No Medical Savings Account 984 773 393 No Annual Threshold Essential Core 1 056 791 422 No Medical Savings Account 1 056 791 422 No Annual Threshold Essential Delta Core network option 844 633 339 No Medical Savings Account 844 633 339 No Annual Threshold Coastal Core 892 669 356 No Medical Savings Account 892 669 356 No Annual Threshold KeyCare Plus (8 301+) 1 211 1 211 324 No Medical Savings Account 1 211 1 211 324 No Annual Threshold KeyCare Plus (6 251 8 300) 813 813 228 No Medical Savings Account 813 813 228 No Annual Threshold KeyCare Plus (3 901 6 250) 581 581 168 No Medical Savings Account 581 581 168 No Annual Threshold KeyCare Plus (0 3 900) 485 485 129 No Medical Savings Account 485 485 129 No Annual Threshold KeyCare Core (8 301+) 894 894 202 No Medical Savings Account 894 894 202 No Annual Threshold KeyCare Core (6 251 8 300) 579 579 144 No Medical Savings Account 579 579 144 No Annual Threshold KeyCare Core (0 6 250) 465 465 117 No Medical Savings Account 465 465 117 No Annual Threshold * We count a maximum of three children when we calculate family contributions, Annual Thresholds and Above Threshold limits. We pro-rate the Annual Thresholds according to when you join the medical scheme. If an adult dependant does not meet our eligibility criteria we will charge the same contribution as the main member s contribution. Average contribution increases per plan for 2012 Adult Child* Series Plan Total Contributions Main member Main member + adult Main member + adult + child Main member + adult + 2 children Main member + adult + 3 children Executive Executive 8.9% 8.9% 8.9% 8.9% 8.9% Comprehensive Priority Saver Core KeyCare Classic Comprehensive 9.0% 8.9% 8.9% 9.0% 9.0% Classic Delta Comprehensive network option 8.9% 8.9% 8.9% 8.9% 8.9% Essential Comprehensive 9.0% 8.9% 8.9% 8.9% 8.9% Essential Delta Comprehensive network option 9.0% 8.9% 8.9% 8.9% 8.9% Classic Priority 9.0% 9.0% 8.9% 8.9% 8.9% Essential Priority 8.9% 8.9% 8.9% 9.0% 9.0% Classic Saver 9.0% 9.0% 9.0% 9.0% 8.9% Classic Delta Saver network option 8.9% 8.9% 8.9% 9.0% 9.0% Essential Saver 9.0% 8.9% 8.9% 8.9% 8.9% Essential Delta Saver network option 8.9% 9.0% 8.9% 8.9% 8.9% Coastal Saver 9.0% 9.0% 9.0% 8.9% 8.9% Classic Core 9.0% 8.9% 8.9% 8.9% 8.9% Classic Delta Core network option 9.0% 8.9% 8.9% 8.9% 8.9% Essential Core 9.0% 9.0% 8.9% 8.9% 8.9% Essential Delta Core network option 8.9% 8.9% 8.9% 8.9% 9.0% Coastal Core 8.9% 8.9% 8.9% 8.9% 8.9% KeyCare Plus Band (8 301+) 8.9% 8.9% 8.9% 8.9% 9.0% KeyCare Plus Band (6251-8300) 8.8% 8.8% 8.9% 9.0% 9.1% KeyCare Plus Band (3 901-6 250) 9.0% 9.0% 8.9% 8.9% 8.8% KeyCare Plus Band (0-3 900) 9.0% 9.0% 8.9% 8.9% 8.8% KeyCare Core Band (8 301+) 8.9% 8.9% 8.9% 8.9% 9.0% KeyCare Core Band (6251-8300) 9.0% 9.0% 9.0% 8.9% 8.8% KeyCare Core Band (0-6 250) 8.9% 8.9% 8.9% 9.0% 9.0% Medical Savings Account amounts are calculated as a percentage of total contributions. Vitality and KeyFIT contributions Single member Member with one dependant Member with two or more dependants Vitality 136 158 167 KeyFIT 29 36 45 Vitality and KeyFIT 145 172 193 KeyClub Starter : R5 000 funeral cover for R1 a month. Discoverer 16 GM_11917DHL_9/09/11