Read Microsoft Word - 2012 Discovery Health - Medical Scheme Update.doc text version


The summary below is as per the information provided by the scheme at their launch for 2012. Should you require any detailed information, please contact HealthGroup directly on 031 266 9426 or [email protected]

SUMMARY Average increase in premiums: Increase applied to: Projected solvency for 2011 year end:

8.9% All options equally <25%


CONTRIBUTION INCREASE: The Discovery Health 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 NEW: DISCOVERY HEALTH MEDSAVER BENEFIT Discovery Health has entered into a venture with Clicks. From January 2012, Discovery Health members will qualify for up to 25% cash back on all schedule 1 and 2 medicines purchased from any Clicks store countrywide. This is a significant saving when one considers that Discovery Health members spent over R550m on over the counter medication in 2010. In order to receive the 25% savings, members will have to activate the benefit on the Discovery website and complete a Vitality check at a pharmacy in the Vitality Wellness Network or at a Wellness Day. The savings will be deposited into the members DiscoveryCard or nominated bank account. NEW: FULL COVER CHOICE Discovery Health have introduced a new logo on their website / marketing material. Members can look for the logo on the right when considering service providers and chronic medicines in 2012. These practitioners / facilities / treatment plans will not exceed the agreed rate with Discovery Health, enabling members to avoid copayments. Please note that not all doctors / specialists subscribe to this. We still recommend that members have top up insurance to protect against potential shortfalls. NEW: ONLINE TOOLS Discovery Health will launch a number of online tools in 2012 to assist members: Hospital Advisor - Calculates whether a member can expect full cover for the hospital and medical specialists he or she has chosen. MaPS Advisor - Allows for a member to locate a healthcare professional who has an agreement with Discovery Health. These healthcare professionals have agreed to charge the Discovery Health Rate for consultations and their claims will be covered in full. Med Advisor - 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 the medicine list and helping members to find a pharmacy in the network where they can avoid shortfalls in dispensing fees. Benefit 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.

NEW: HospitalXpress 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. Services include: Hospital Advisor - to find a facility with full cover Online Authorisation - no need to contact the call centre Online express preadmission - complete all the hospital forms prior to arrival. Patient information - Discovery have created medical brochures on all common conditions so that you will know what to expect Value added services - Discovery will assist you with point to point transfers, providing portable DVD entertainment, internet connectivity and personal grooming services for your stay in hospital Event summary - a comprehensive summary of your entire hospital event, showing exactly what costs have been covered NEW: PracticeXpress Discovery will be supplying over 5,000 iPad's to GP's within its GP network, providing them with real time information on their members. The core functionality of PracticeXpress provides a suite of tools which will: Enhance the quality of care for Discovery Health members by providing doctors with an integrated view of a patient's medical history 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 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. UPDATES TO EXISTING BENEFITS 2012 ALLIED AND THERAPEUTIC BENEFIT Discovery Health has redesigned the allied health benefits on Executive, Comprehensive and Priority plans for 2012. The new design is intended to provide enhanced cover for nursing and psychiatry treatments, offer more flexible cover across different medical disciplines and provide unlimited cover for serious conditions. Less than 5% of members are expected to exceed the benefits available.*

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 Mental health benefit: R12 000 to R16 000 Home nursing benefit: R6 650 a family Covered through Above Threshold Benefit with no sub-limits 2012 benefit Covered as a specialist out-patient consultation, with no sub-limit Cover provided through the Allied and Therapeutic Benefit:

Note: These changes do not apply to the Saver, Core and KeyCare series of plans. ALLIED AND THERAPEUTIC EXTENDER BENEFIT* For those who do exceed their benefits, the Allied and Therapeutic Extender Benefit will provide unlimited cover for a list of allied healthcare services, including physiotherapy, to members who meet the clinical entry criteria. This benefit will cater for members with severe, complex conditions who require short-term or long-term assistance from allied healthcare professionals. Updates to limits, co-payments, deductibles and thresholds 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%. Review of adult dependant eligibility criteria The intention of the adult dependant contribution is to provide the family unit with cover at an appropriate and affordable rate. Discovery have noticed an increase in the number of dependants joining health plans as adult dependants at this discounted contribution, which 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, Discovery 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. Discovery Health Medicine Rate The Discovery Health 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 Discovery Health members at this rate. This is a significant achievement which will allow members to avoid copayments. KeyCare changes for 2012 KeyCare Hospital Network changes: 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, Discovery introduced a network of day-case facilities through which members have access to full cover for a defined list of minor procedures. In 2012, they 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:

Changes to the KeyCare Casualty Benefit: 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.

DISCLAIMER The information contained in this guide is as per the Health Discoverer provided to accredited intermediaries at the Discovery Health 2012 benefit presentation. Certain benefits may be subject to approval by the Council for Medical Schemes. The registered rules of Discovery Health supersede this guide at all times.


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