1IBM Induction Presentation – Discovery Health Presented by Nkosinathi Siyoko
2Agenda AF Health’s commitment to you FAIS requirements Discovery Health product rangeVitality
3AF Health’s commitment to you We provide:Assistance in choosing the correct medical scheme option, based on your needsClarification of benefits and the escalation of any unresolved medical scheme queriesLiaison with your medical scheme on your behalf to ensure you are treated fairly and correctly, based on your benefit entitlements.To your employer we provide:Industry updates that could affect your business and membersStrategic consulting to the employer.
4FAIS requirementsAlexander Forbes Health is an approved Financial Services Provider – FSP 33471Alexander Forbes Health is accredited by the Council for Medical Schemes – ORG 3064All information provided in this presentation is factual and NO advice is providedGeneral Disclosure and Product Supplier Disclosures are available upon requestAlexander Forbes Health are appointed brokers to administrators and open medical schemes (actuarial and consulting services).
5Agenda AF Health’s commitment to you FAIS requirements Discovery Health product rangeVitality
6Discovery Health product range ComprehensiveClassic/ Essential200%/ 100%Chronic: 61MSA: 0%/15%/ 25%ThresholdPriorityClassic/ Essential200%/ 100%Chronic: 26MSA: 15%/25%Limited ThresholdSaverClassic/ Essential/ Coastal200%/100%Chronic: 26MSA: 15%/25%CoreClassic/ Essential/ Coastal200%/100%Chronic: 26No MSAKeycarePlus/ Core/ Access100%Chronic: 26NetworksPrimary care
7Discovery Health product range THE DELTA PLAN RANGEComprehensive Saver Core10% premium reduction20% premium reduction
8Discovery Health product range THE DELTA HOSPITAL NETWORKJohannesburgArwypBedford GardensBrenthurstCarstenhofClinix – LesediClinix - SebogengClintonEmfuleniFourwaysLenmedMorningsideRobinsonRoseacresThe Donald GordonWilgeheuwelPlus 10 day clinicsVaalMidvaalSuikerbosrandPlus 6 day clinicsPretoriaBougainvilleLegaeLittle Company of MaryLouis PasteurPlus 8 day clinicsDurbanChatsmedEntabeniEthekwiniWestvillePlus 1 day clinicBloemfonteinLife RoseparkUniversitasPlus 3 day clinicsWestern CapeCape Town Medi-ClinicClaremontKingsburyMitchells PlainPanoramaVergelegenPlus 13 day clinicsPietermaritzburgMidlandsEastern CapeLife New MercantileDeductible of R5 450 if non-Delta hospital usedMed XPress must be used for chronic medication, or 20% co-payment
9Discovery Health product range THE CORE SERIESHospital BenefitCovers approved hospitalization with no overall limitFull cover when using specialist in one of DH’s Direct Payment ArrangementsMRI on Back and neck surgery not coveredNo Day to Day CoverChronic Illness BenefitCover for 26 conditionsSubject to formulary orlower Chronic Drug AmountPreventive Screening BenefitVitalityCheck and other screenings
10Discovery Health product range MemberClassic CoreClassic Delta CoreEssential CoreEssential Delta CoreCoastal CoreMain MemberR1 471R1 177R1 263R1010R1 087Spouse/Adult DependantR1 157R925R947R757R815Child DependantR587R471R506R405R434
11Discovery Health product range THE SAVER SERIESNO Above Threshold BenefitInsured Network BenefitGP’s Single FamilyClassic & Coastal 3 visits 6 visitsEssential 2 visits 4 visitsMaternity BenefitClassic Plans 8 antenatal consultstwo 2D scansHospital BenefitCovers approved hospitalisation with no overall limitFull cover when using specialist in one of DH’s direct payment arrangementsChronic Illness BenefitCover for 26 conditionsSubject to formulary orlower Chronic Drug AmountMedical Savings AccountPays day-to-day medical costsFull annual deposit availableup frontClassic: 25%Essential 15%Coastal: 25%Preventive Screening BenefitVitalityCheck and other screenings
13Discovery Health product range Above Threshold Benefit (ATB)Limited ‘safety-net’ for day-to-day expensesPaid by Discovery at the DH Rate onceday-to-day claims reach certain levelThreshold ATB LimitsPM: PM:Adult: Adult:Child: Child:THE PRIORITY SERIESHospital BenefitCovers approved hospitalization with no overall limitFull cover when using specialist in one of DH’s direct payment arrangementsDefined procedures attract deductiblesInsured Network BenefitGP through network during SPGPathology at DSP on Classic optionMaternity Benefit on Classic optionDefined list of External Medical items on Classic & EssentialChronic Illness Benefit26 conditions (CDL)Subject to formulary orlower Chronic Drug AmountPreventive Screening BenefitVitalityCheck and otherscreeningsMedical Savings AccountClassic: 25%Essential 15%
14Discovery Health product range THE PRIORITY SERIESThe Priority Plan has deductibles applicable to the following procedures:Deductibles2014Conservative back and neck treatment, myringotomy (grommets), tonsillectomy, adenoidectomyR2 150Colonoscopy, Proctoscopy, Sigmoidoscopy, Gastroscopy, CystoscopyR2 850Arthroscopy, functional nasal procedures, hysterectomy, endometrial ablation, LaparoscopyR5 150Reflux surgery, spinal surgery (back and neck) surgery and joint replacementsR10 500
15Discovery Health pays for claims from the ATB Discovery Health Product RangeTHE THRESHOLD LEVELFOR 2014 = R11,350Discovery Health pays for claims from the ATB‘Automatic’ SPG = R1,270Increase SPGTo R4,673AT COSTRATE OF ACCUMULATION= R 0GP Consultation (Network) – R320Non-Premier Rate SpecialistConsultation (DH Rate) + R520Claimsaccumulated= R6,677Non -preferred Medicine List Medication- R852OTC medication (S 0,1 or 2) + R0Premier Rate Specialist Consultation- R498(Non-network) Glasses + R3,500X-rays – R1,200X-rays (DH Rate) + R1,200Glasses limit correct.Glasses – R5,780Premier Rate Specialist Consultation+ R498OTC Medication (S 0, 1 or 2) – R630Non –preferred Medicine List Medication+ R639GP consultation (Network) + R320Non-Premier Rate SpecialistConsultation – R800Based on a single member on the Classic Comprehensive OptionRates are examplesMSA for the year : R10,080
16Additional enhancements to www.discovery.co.za The Self-payment Gap trackerThe SPG Tracker provides detailed information on what has contributed towards the Self-payment Gap, without the need to request this information through a different channelAvailable online from January 2014
17Discovery Health product range MemberClassic PriorityEssential PriorityMain memberR2 254R1 937Spouse/adult dependantR1 774R1 522Child dependantR902R774
18Discovery Health product range Above Threshold Benefit (ATB)Unlimited ‘safety-net’ for day-to-day expenses subject to certain sub-limitsPaid by Discovery at the DH Rate onceday-to-day claims reach certain levelThreshold 2014PM:Adult:Child:THE COMPREHENSIVE SERIESHospital BenefitCovers approved hospitalization with no overall limitFull cover when using specialist in one of DH’s direct payment arrangementsChronic Illness BenefitCover for 61 conditions(27 CDL & 34 ADL)Insured Network BenefitGP, External medical items – all options except Classic Comp Zero MSAMaternity, Pathology & Generic Meds (Formulary) – On Classic & Classic DeltaDSP AppliesPreventive Screening BenefitVitalityCheck & other screeningsMedical Savings AccountClassic: 25%Essential 15%Zero 0%
19Discovery Health product range THE EXECUTIVE PLANAbove Threshold Benefit (ATB)Unlimited ‘safety-net’ for day-to-day expenses subject to certain sub-limitsPaid by Discovery at the DH Rate onceday-to-day claims reach certain levelThreshold 2014PM:Adult:Child:Hospital BenefitCovers approved hospitalization with no overall limitSpecialists in hospital paid up to 300% of the DH Rate from MSA/ATBPrivate ward cover R1 400 per dayChronic Illness BenefitCover for 61 conditions(27 CDL & 34 ADL)Additional Medicines coveredInsured Network BenefitGP, Pathology, PML, External medical items & Maternity benefit 100% cost through network during SPGMedical Savings AccountMinimal gap between MSA and ATBSpecialists covered up to 300% of Discovery Health ratePreventive Screening BenefitVitalityCheck & other screenings
20Discovery Health product range MemberExecutive PlanClassic CompClassic Delta CompEssential CompEssential Delta CompClassic Zero MSAMain MemberR4 100R3 362R3 028R2 825R2 544R2 522Spouse/Adult DependantR3 180R2 864R2 670R2 403R2 385Child DependantR778R670R602R568R509R503
22Discovery Health product range CHRONIC ILLNESS BENEFIT –Comprehensive and Executive plans only1Ankylosing spondylitis18Paget’s disease2Behçet’s disease19Panic disorder3Connective tissue disorder (mixed)20Paraplegia4Cushing’s disease21Pemphigus5Cystic fibrosis22Peripheral arteriosclerotic disease6Delusional disorder23Pituitary microadenomas7Dermatopolymyositis24Polyarteritis Nodosa8Generalised anxiety disorder25Post traumatic stress disorder9Huntington’s disease26Psoriatic arthritis10Hypoparathyroidism27Pulmonary interstitial fibrosis11Major depression28Quadriplegia12Motor neurone disease29Sjögren’s syndrome13Muscular dystrophy and other inherited myopathies*30Stroke14Myasthenia gravis31Systemic sclerosis15Obsessive compulsive disorder32Thrombocytopaenia purpura16Organ transplantation33Valvular heart disease17Osteoporosis34Wegener’s granulomatosisMedicine list changeNew formularyMust register/ formulary /CDA
23MedXpress delivers your medication to your door MedXpress delivers medicine directly to members at no extra costWhat does it cover?AcuteChronicLocations deliveredMajor Metropolitan areas*CountrywideTime to delivery6 hours**72 hoursConvenience for membersDelivery to your door, Simple process with no forms, Delivery tracking, Regular updates on changesHelps members to better manage costsLow dispensing fees, No administration or delivery fees, Advice on generic substitution to ensure lower or no co-paymentsAccess to more information about their treatment/conditionWhy should members use it?MedXpress currently processes on average 6000 chronic orders per month.The current member user base is in the region of Acute orders are still pretty low averaging at about 20 per month.42% of MedXpress members claim formulary items and attract no co-payment compared with 34% at all other pharmacies.12% co-pay as % of claim versus 19% for other pharmacies.How to order or re-order:Member AppWebsiteCall MedXpressDiscovery Walk-in centreSMS re-order serviceHow does a member use it?To order or re-order medicine, members can use any of the following:SMS re-order serviceNote: *Johannesburg, Cape Town, Pretoria, Durban, Port ElizabethNote: **For medicine ordered before 15:00
24MedXpress as designated service provider for Delta options 1Effective from 1 January 2014 for all new members and 1 July for all existing Delta plan members2Chronic medication of Delta members registered for CIB will be covered in full if:Ordered through MedXpressChronic medicine is on the formularyChronic medicine is off the formulary, but under the CDAIn other cases, member will face a co-paymentFundingOrdered through MedXpressNot ordered through MedXpressOn formularyFull Cover20% co-payment+Any additional dispensing feesOff formularyCo-payment above CDA
25The KeyCare Series in summary KeyCare PlusKeyCare AccessKeyCare CoreCritical hospital carePlannedhospital careChronic Illness BenefitsDay-to-day medical careScreening and preventionKeyFITKeyCare Hospital NetworkKeyCare Hospital Network for emergencies and trauma;KeyCare Access Hospital Network* for child birth and care of newbornsKeyCare Hospital NetworkKeyCare Hospital NetworkContracted state hospitalsKeyCare Hospital NetworkCover for antenatal services and specialist consultations*A network of 32 private hospitals
26Discovery Health product range THE KEYCARE PLANSUnlimited emergency hospitalisation - Any hospital, transfer to network hospital once stableCriticalhospital carePlannedChronic Illness BenefitsDay-to-day medical careScreening and preventionVitality & KeyFITUnlimited planned hospitalization at a Network hospital only, otherwise there is no benefitCovers 26 Chronic conditions subject to formulary and approved network supplier or their dispensing doctor. A 20% co-pay applies outside of the network.Through Discovery Health provider networkGP consultations and minor proceduresMedication subj. to formularyBasic blood tests and x-raysBasic dentistryBasic optometry, frames and lensesMembers may elect a secondary GP per beneficiary. One out of network visit pbpaSpecialist Benefit- R2 750 pp (2013:R2550)Antenatal benefit- 4 consults; 2 scan, selected blood testsMobility device benefit – R4450 per familyCasualty BenefitThe casualty fee for ALL Keycare casualty units is R225Formularies apply in casualtyScreening benefitAntenatal Benefit covers you at 100% of the Discovery Health Ratefor the following healthcare services:• Four visits to a GP or gynaecologist at a network hospital• One routine scan (between 10 and 20 weeks)• Selected blood tests requested by your gynaecologist or GPWe cover wheelchairs, wheelchair batteries and cushions, transfer boards and mobileramps, commodes, long-leg calipers, crutches and walkers on the medical equipment list,if you get them from a network provider. There is an overall limit of R4 450 for each family.
27This list applies to KeyCare Access, only for childbirth and care for the newborn Applies to the KeyCare Core and Plus plans;Applies to KeyCare Access but only for life threatening emergencies and defined trauma events
28Discovery Health product range Plan optionIncome bracketMain memberSpouse/adult dependantChild dependantKeycare Plus(R0 – R6 650)R695R251(R6 651 – R8 800)R973R272(R8 801+)R1 448R388Keycare CoreR556R143R693R171R1 070R241Keycare Access(R0 - R3900)R490R212
29Agenda AF Health’s commitment to you FAIS requirements Discovery Health product rangeVitality
30Vitality’s model of making members healthier IMPROVE YOUR HEALTHEngage in activities and earn pointsENJOY THE REWARDSAchieve a Vitality Status and enjoy the rewardsKNOW YOUR HEALTHComplete the Vitality assessmentsNo Vitality carry over points to 2014
31HealthyFood benefit structure revised to incentivise screening Activate the benefit on discovery.co.zaDetermine your Vitality Age*Complete aVitality Health Check*201410%cash back at both partners15%cash back at your preferred partner, 10% at the otherMembers without a DiscoveryCard10%cash back at both partners15%Members with a DiscoveryCard*Principal , spouse and adult dependant (where applicable) need to complete a VHR and Vitality Check
32Over 100 international destinations are now available 31 British AirwaysInternational destinations13 EmiratesInternational destinations101 New Emirates International destinationsIn 2012, Vitality members booked over one million discounted flights, filled up 19 planes every day, covered over three million kms and saved themselves R231 million8 QantasInternational destinationsBlueBronzeSilverGoldDiamond15%20%25%30%35%
33Enhanced rewards: Introducing the Vitality Hotel Collection Fully integrated booking on kulula.comL’ermitage Franschhoek15 on OrangeCape TownThe Beverly HillsUmhlangaPumba Private Game ReservePort ElizabethSimbambili Game LodgeKruger National ParkThe Melrose Arch HotelJohannesburgand more…Over 500 top hotels, lodges and resortsMinimum of 2 nights per booking -Booking must be made 21 days in advance-Maximum of 14 nights per yearBooking no longer needs to include a Saturday nightBlueBronzeSilverGoldDiamond15%20%25%30%35%50%45%40%
34Gap Cover Insurance - Admed Gap Admed Add+ is a voluntary top-up benefit to cover shortfalls in hospitalsAdmed Add+Shortfall CoverThe shortfall , or gap, is defined as the amount by which the actual cost charged by the medical practitioner exceeds the medical scheme payment subject to a maximum limit of five times the Admed tariff, less the medical scheme paymentAdditional BenefitsPersonal Accident CoverRoad CoverA once off lump sum of R on diagnosis of Breast and Prostate cancerA stated benefit of R with no sub limits for co-payments and deductibles (in hospital treatment)All shortfalls on MRI/CT/PET Scans done on an outpatient basis will be covered by Admed+ option - this amount would be covered by the stated benefit amount of R20 000. Oncology benefit – 20% co-payment that members are subjected to once they reach their limit, will be covered up to a max of the benefit limit of R250 000 pbpa.
35Gap Cover Insurance - Admed Gap Admed Add+Additional BenefitsShortfalls resulting from MRI/CT/PET Scans done on an outpatient basis will be covered from Covered by the stated benefit amount of R20,000Oncology benefit – 20% co-payment that members are subjected to once they reach their oncology benefit limit, will be covered up to a max of the benefit limit of R250,000 per beneficiary per annumRate from 1 January 2014Active members: R101Retirees: R154Guardrisk contact details:Tel:All shortfalls on MRI/CT/PET Scans done on an outpatient basis will be covered by Admed+ option - this amount would be covered by the stated benefit amount of R20 000. Oncology benefit – 20% co-payment that members are subjected to once they reach their limit, will be covered up to a max of the benefit limit of R250 000 pbpa.
36For assistance contact us Our dedicated Service Team:SMS the word ‘medical aid’ to and one of our consultants will call you back (SMS charged at standard rates)Discovery Health (24hrs) or access the website at