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IBM Induction Presentation – Discovery Health
Presented by Nkosinathi Siyoko
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Agenda AF Health’s commitment to you FAIS requirements
Discovery Health product range Vitality
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AF Health’s commitment to you
We provide: Assistance in choosing the correct medical scheme option, based on your needs Clarification of benefits and the escalation of any unresolved medical scheme queries Liaison 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 members Strategic consulting to the employer.
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FAIS requirements Alexander Forbes Health is an approved Financial Services Provider – FSP 33471 Alexander Forbes Health is accredited by the Council for Medical Schemes – ORG 3064 All information provided in this presentation is factual and NO advice is provided General Disclosure and Product Supplier Disclosures are available upon request Alexander Forbes Health are appointed brokers to administrators and open medical schemes (actuarial and consulting services).
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Agenda AF Health’s commitment to you FAIS requirements
Discovery Health product range Vitality
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Discovery Health product range
Comprehensive Classic/ Essential 200%/ 100% Chronic: 61 MSA: 0%/15%/ 25% Threshold Priority Classic/ Essential 200%/ 100% Chronic: 26 MSA: 15%/25% Limited Threshold Saver Classic/ Essential/ Coastal 200%/100% Chronic: 26 MSA: 15%/25% Core Classic/ Essential/ Coastal 200%/100% Chronic: 26 No MSA Keycare Plus/ Core/ Access 100% Chronic: 26 Networks Primary care
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Discovery Health product range
THE DELTA PLAN RANGE Comprehensive Saver Core 10% premium reduction 20% premium reduction
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Discovery Health product range
THE DELTA HOSPITAL NETWORK Johannesburg Arwyp Bedford Gardens Brenthurst Carstenhof Clinix – Lesedi Clinix - Sebogeng Clinton Emfuleni Fourways Lenmed Morningside Robinson Roseacres The Donald Gordon Wilgeheuwel Plus 10 day clinics Vaal Midvaal Suikerbosrand Plus 6 day clinics Pretoria Bougainville Legae Little Company of Mary Louis Pasteur Plus 8 day clinics Durban Chatsmed Entabeni Ethekwini Westville Plus 1 day clinic Bloemfontein Life Rosepark Universitas Plus 3 day clinics Western Cape Cape Town Medi-Clinic Claremont Kingsbury Mitchells Plain Panorama Vergelegen Plus 13 day clinics Pietermaritzburg Midlands Eastern Cape Life New Mercantile Deductible of R5 450 if non-Delta hospital used Med XPress must be used for chronic medication, or 20% co-payment
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Discovery Health product range
THE CORE SERIES Hospital Benefit Covers approved hospitalization with no overall limit Full cover when using specialist in one of DH’s Direct Payment Arrangements MRI on Back and neck surgery not covered No Day to Day Cover Chronic Illness Benefit Cover for 26 conditions Subject to formulary or lower Chronic Drug Amount Preventive Screening Benefit VitalityCheck and other screenings
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Discovery Health product range
Member Classic Core Classic Delta Core Essential Core Essential Delta Core Coastal Core Main Member R1 471 R1 177 R1 263 R1010 R1 087 Spouse/ Adult Dependant R1 157 R925 R947 R757 R815 Child Dependant R587 R471 R506 R405 R434
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Discovery Health product range
THE SAVER SERIES NO Above Threshold Benefit Insured Network Benefit GP’s Single Family Classic & Coastal 3 visits 6 visits Essential 2 visits 4 visits Maternity Benefit Classic Plans 8 antenatal consults two 2D scans Hospital Benefit Covers approved hospitalisation with no overall limit Full cover when using specialist in one of DH’s direct payment arrangements Chronic Illness Benefit Cover for 26 conditions Subject to formulary or lower Chronic Drug Amount Medical Savings Account Pays day-to-day medical costs Full annual deposit available up front Classic: 25% Essential 15% Coastal: 25% Preventive Screening Benefit VitalityCheck and other screenings
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Discovery Health product range
Member Classic Saver Classic Delta Saver Essential Saver Essential Delta Saver Coastal Saver Main Member R1 976 R1 578 R1 570 R1 254 R1 556 Spouse/ Adult Dependant R1 244 R1 175 R 942 R1 166 Child Dependant R790 R633 R628 R502 R625
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Discovery Health product range
Above Threshold Benefit (ATB) Limited ‘safety-net’ for day-to-day expenses Paid by Discovery at the DH Rate once day-to-day claims reach certain level Threshold ATB Limits PM: PM: Adult: Adult: Child: Child: THE PRIORITY SERIES Hospital Benefit Covers approved hospitalization with no overall limit Full cover when using specialist in one of DH’s direct payment arrangements Defined procedures attract deductibles Insured Network Benefit GP through network during SPG Pathology at DSP on Classic option Maternity Benefit on Classic option Defined list of External Medical items on Classic & Essential Chronic Illness Benefit 26 conditions (CDL) Subject to formulary or lower Chronic Drug Amount Preventive Screening Benefit VitalityCheck and other screenings Medical Savings Account Classic: 25% Essential 15%
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Discovery Health product range
THE PRIORITY SERIES The Priority Plan has deductibles applicable to the following procedures: Deductibles 2014 Conservative back and neck treatment, myringotomy (grommets), tonsillectomy, adenoidectomy R2 150 Colonoscopy, Proctoscopy, Sigmoidoscopy, Gastroscopy, Cystoscopy R2 850 Arthroscopy, functional nasal procedures, hysterectomy, endometrial ablation, Laparoscopy R5 150 Reflux surgery, spinal surgery (back and neck) surgery and joint replacements R10 500
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Discovery Health pays for claims from the ATB
Discovery Health Product Range THE THRESHOLD LEVELFOR 2014 = R11,350 Discovery Health pays for claims from the ATB ‘Automatic’ SPG = R1,270 Increase SPG To R4,673 AT COST RATE OF ACCUMULATION = R 0 GP Consultation (Network) – R320 Non-Premier Rate Specialist Consultation (DH Rate) + R520 Claims accumulated = R6,677 Non -preferred Medicine List Medication - R852 OTC medication (S 0,1 or 2) + R0 Premier Rate Specialist Consultation - R498 (Non-network) Glasses + R3,500 X-rays – R1,200 X-rays (DH Rate) + R1,200 Glasses limit correct. Glasses – R5,780 Premier Rate Specialist Consultation + R498 OTC Medication (S 0, 1 or 2) – R630 Non –preferred Medicine List Medication + R639 GP consultation (Network) + R320 Non-Premier Rate Specialist Consultation – R800 Based on a single member on the Classic Comprehensive Option Rates are examples MSA for the year : R10,080
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Additional enhancements to www.discovery.co.za
The Self-payment Gap tracker The SPG Tracker provides detailed information on what has contributed towards the Self-payment Gap, without the need to request this information through a different channel Available online from January 2014
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Discovery Health product range
Member Classic Priority Essential Priority Main member R2 254 R1 937 Spouse/adult dependant R1 774 R1 522 Child dependant R902 R774
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Discovery Health product range
Above Threshold Benefit (ATB) Unlimited ‘safety-net’ for day-to-day expenses subject to certain sub-limits Paid by Discovery at the DH Rate once day-to-day claims reach certain level Threshold 2014 PM: Adult: Child: THE COMPREHENSIVE SERIES Hospital Benefit Covers approved hospitalization with no overall limit Full cover when using specialist in one of DH’s direct payment arrangements Chronic Illness Benefit Cover for 61 conditions (27 CDL & 34 ADL) Insured Network Benefit GP, External medical items – all options except Classic Comp Zero MSA Maternity, Pathology & Generic Meds (Formulary) – On Classic & Classic Delta DSP Applies Preventive Screening Benefit VitalityCheck & other screenings Medical Savings Account Classic: 25% Essential 15% Zero 0%
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Discovery Health product range
THE EXECUTIVE PLAN Above Threshold Benefit (ATB) Unlimited ‘safety-net’ for day-to-day expenses subject to certain sub-limits Paid by Discovery at the DH Rate once day-to-day claims reach certain level Threshold 2014 PM: Adult: Child: Hospital Benefit Covers approved hospitalization with no overall limit Specialists in hospital paid up to 300% of the DH Rate from MSA/ATB Private ward cover R1 400 per day Chronic Illness Benefit Cover for 61 conditions (27 CDL & 34 ADL) Additional Medicines covered Insured Network Benefit GP, Pathology, PML, External medical items & Maternity benefit 100% cost through network during SPG Medical Savings Account Minimal gap between MSA and ATB Specialists covered up to 300% of Discovery Health rate Preventive Screening Benefit VitalityCheck & other screenings
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Discovery Health product range
Member Executive Plan Classic Comp Classic Delta Comp Essential Comp Essential Delta Comp Classic Zero MSA Main Member R4 100 R3 362 R3 028 R2 825 R2 544 R2 522 Spouse/ Adult Dependant R3 180 R2 864 R2 670 R2 403 R2 385 Child Dependant R778 R670 R602 R568 R509 R503
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Discovery Health product range
CHRONIC ILLNESS BENEFIT (PMBs) 1 Addison’s disease 14 Epilepsy 2 Asthma 15 Glaucoma 3 Bronchiectasis 16 Haemophilia 4 Bipolar Mood Disorder 17 HIV/AIDS 5 Cardiac Failure 18 Hyperlipedaemia (High Cholesterol) 6 Cardiomyopathy 19 Hypertension (High Blood Pressure) 7 Chronic Obstructive Pulmonary Disease (Emphysema) 20 Hypothyroidism (Inactive Thyroid Gland) 8 Chronic Kidney Disease 21 Multiple Sclerosis 9 Coronary Artery Disease 22 Parkinson’s Disease 10 Crohn's disease 23 Rheumatoid Arthritis 11 Diabetes Insipidus 24 Schizophrenia 12 Diabetes Mellitus (Type 1 & 2) 25 Systemic Lupus Erythomatosis 13 Dysrhythmia (Irregular Heartbeat) 26 Ulcertative Colitis
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Discovery Health product range
CHRONIC ILLNESS BENEFIT – Comprehensive and Executive plans only 1 Ankylosing spondylitis 18 Paget’s disease 2 Behçet’s disease 19 Panic disorder 3 Connective tissue disorder (mixed) 20 Paraplegia 4 Cushing’s disease 21 Pemphigus 5 Cystic fibrosis 22 Peripheral arteriosclerotic disease 6 Delusional disorder 23 Pituitary microadenomas 7 Dermatopolymyositis 24 Polyarteritis Nodosa 8 Generalised anxiety disorder 25 Post traumatic stress disorder 9 Huntington’s disease 26 Psoriatic arthritis 10 Hypoparathyroidism 27 Pulmonary interstitial fibrosis 11 Major depression 28 Quadriplegia 12 Motor neurone disease 29 Sjögren’s syndrome 13 Muscular dystrophy and other inherited myopathies* 30 Stroke 14 Myasthenia gravis 31 Systemic sclerosis 15 Obsessive compulsive disorder 32 Thrombocytopaenia purpura 16 Organ transplantation 33 Valvular heart disease 17 Osteoporosis 34 Wegener’s granulomatosis Medicine list change New formulary Must register/ formulary /CDA
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MedXpress delivers your medication to your door
MedXpress delivers medicine directly to members at no extra cost What does it cover? Acute Chronic Locations delivered Major Metropolitan areas* Countrywide Time to delivery 6 hours** 72 hours Convenience for members Delivery to your door, Simple process with no forms, Delivery tracking, Regular updates on changes Helps members to better manage costs Low dispensing fees, No administration or delivery fees, Advice on generic substitution to ensure lower or no co-payments Access to more information about their treatment/condition Why 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 App Website Call MedXpress Discovery Walk-in centre SMS re-order service How does a member use it? To order or re-order medicine, members can use any of the following: SMS re-order service Note: *Johannesburg, Cape Town, Pretoria, Durban, Port Elizabeth Note: **For medicine ordered before 15:00
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MedXpress as designated service provider for Delta options
1 Effective from 1 January 2014 for all new members and 1 July for all existing Delta plan members 2 Chronic medication of Delta members registered for CIB will be covered in full if: Ordered through MedXpress Chronic medicine is on the formulary Chronic medicine is off the formulary, but under the CDA In other cases, member will face a co-payment Funding Ordered through MedXpress Not ordered through MedXpress On formulary Full Cover 20% co-payment + Any additional dispensing fees Off formulary Co-payment above CDA
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The KeyCare Series in summary
KeyCare Plus KeyCare Access KeyCare Core Critical hospital care Planned hospital care Chronic Illness Benefits Day-to-day medical care Screening and prevention KeyFIT KeyCare Hospital Network KeyCare Hospital Network for emergencies and trauma; KeyCare Access Hospital Network* for child birth and care of newborns KeyCare Hospital Network KeyCare Hospital Network Contracted state hospitals KeyCare Hospital Network Cover for antenatal services and specialist consultations *A network of 32 private hospitals
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Discovery Health product range
THE KEYCARE PLANS Unlimited emergency hospitalisation - Any hospital, transfer to network hospital once stable Critical hospital care Planned Chronic Illness Benefits Day-to-day medical care Screening and prevention Vitality & KeyFIT Unlimited planned hospitalization at a Network hospital only, otherwise there is no benefit Covers 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 network GP consultations and minor procedures Medication subj. to formulary Basic blood tests and x-rays Basic dentistry Basic optometry, frames and lenses Members may elect a secondary GP per beneficiary. One out of network visit pbpa Specialist Benefit- R2 750 pp (2013:R2550) Antenatal benefit- 4 consults; 2 scan, selected blood tests Mobility device benefit – R4450 per family Casualty Benefit The casualty fee for ALL Keycare casualty units is R225 Formularies apply in casualty Screening benefit Antenatal Benefit covers you at 100% of the Discovery Health Rate for 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 GP We cover wheelchairs, wheelchair batteries and cushions, transfer boards and mobile ramps, 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.
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This 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
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Discovery Health product range
Plan option Income bracket Main member Spouse/ adult dependant Child dependant Keycare Plus (R0 – R6 650) R695 R251 (R6 651 – R8 800) R973 R272 (R8 801+) R1 448 R388 Keycare Core R556 R143 R693 R171 R1 070 R241 Keycare Access (R0 - R3900) R490 R212
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Agenda AF Health’s commitment to you FAIS requirements
Discovery Health product range Vitality
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Vitality’s model of making members healthier
IMPROVE YOUR HEALTH Engage in activities and earn points ENJOY THE REWARDS Achieve a Vitality Status and enjoy the rewards KNOW YOUR HEALTH Complete the Vitality assessments No Vitality carry over points to 2014
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HealthyFood benefit structure revised to incentivise screening
Activate the benefit on discovery.co.za Determine your Vitality Age* Complete a Vitality Health Check* 2014 10% cash back at both partners 15% cash back at your preferred partner, 10% at the other Members without a DiscoveryCard 10% cash back at both partners 15% Members with a DiscoveryCard *Principal , spouse and adult dependant (where applicable) need to complete a VHR and Vitality Check
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Over 100 international destinations are now available
31 British Airways International destinations 13 Emirates International destinations 101 New Emirates International destinations In 2012, Vitality members booked over one million discounted flights, filled up 19 planes every day, covered over three million kms and saved themselves R231 million 8 Qantas International destinations Blue Bronze Silver Gold Diamond 15% 20% 25% 30% 35%
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Enhanced rewards: Introducing the Vitality Hotel Collection
Fully integrated booking on kulula.com L’ermitage Franschhoek 15 on Orange Cape Town The Beverly Hills Umhlanga Pumba Private Game Reserve Port Elizabeth Simbambili Game Lodge Kruger National Park The Melrose Arch Hotel Johannesburg and more… Over 500 top hotels, lodges and resorts Minimum of 2 nights per booking -Booking must be made 21 days in advance -Maximum of 14 nights per year Booking no longer needs to include a Saturday night Blue Bronze Silver Gold Diamond 15% 20% 25% 30% 35% 50% 45% 40%
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Gap Cover Insurance - Admed Gap
Admed Add+ is a voluntary top-up benefit to cover shortfalls in hospitals Admed Add+ Shortfall Cover The 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 payment Additional Benefits Personal Accident Cover Road Cover A once off lump sum of R on diagnosis of Breast and Prostate cancer A 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.
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Gap Cover Insurance - Admed Gap
Admed Add+ Additional Benefits Shortfalls resulting from MRI/CT/PET Scans done on an outpatient basis will be covered from Covered by the stated benefit amount of R20,000 Oncology 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 annum Rate from 1 January 2014 Active members: R101 Retirees: R154 Guardrisk 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.
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For 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
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Thank You
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