November 2011
Dear Life Healthcare Employee- Discovery Health member
DISCOVERY HEALTH MEDICAL SCHEME CHANGES FOR 2012
Discovery Health Medical Scheme recently made their 2012 benefits and contributions available and youare once again given the opportunity to change your plan option with effect from 1 January 2012. You therefore need to consider your healthcare requirements for the following year and decide if you have the cover appropriate to your needs. You are under no obligation to change your plan option however if you want to change your current plan option, you would need to submit your new plan option information to your FPA (Frontline Payroll Administrator)/ payroll administrator, within 5 days from your business unit’s presentation. Option changes will not be accepted after the 25th November 2011.
CHANGING YOUR PLAN OPTION
Discovery Health Medical Scheme will send you a brochure on behalf ofAlexander Forbes Health containing a detailed summary of the 2012 benefits and rates – after carefully studying the changes for 2012 you will need to decide whether you wish to change your plan option.
Please note that if you do not notify your FPA / payroll administratorof your plan option prior to the above deadline date, by completing the attached option change form (Annexure D), you will remain on your current option and only be afforded another opportunity to change your option in November 2012 for January 2013.
ASSISTANCE WITH CHOOSING YOUR PLAN OPTION
There are four channels of assistance available to you:
- Member Presentations
Presentations will be held in the following regions between the 31st October 2011 and 25November2011. Please watch your notice boards for details of venues, dates and times.
Region / No Of PresentationsBloemfontein / 13
East London / 24
Gauteng East / 33
Gauteng North / 24
Gauteng West / 39
Kwazulu Natal / 44
Port Elizabeth / 22
Western Cape / 24
Other / 43
Total / 264
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- Discovery Health Medical Scheme
Members may contact the Discovery Health Medical Schemefor general plan information by:
- Phoning 0860 100 694;
- Browsing the website
- Making use of the national walk-in centres
- DvD – training dvd’s will be available from your FPA
- Vitality magazine (Spring edition)
- Alexander Forbes Health
Alexander Forbes Health consultants will be available at the member presentations to assist you to make the right plan option choice and to provide advice. You can also contact a consultant on:
Alexander Forbes Health office / Tel number / Email addressSandton office / 011 269 2690 /
Stellenbosch office / 021 809 3777 /
- Healthcare Website
You may also access the healthcare website on your Company’s intranet for all the 2012 benefit information, or log onto
CONTRIBUTIONS
We believe that Discovery Health Medical Scheme’s average contribution increase, effective 1 January 2012, of 8.9% reflects a positive view of the Scheme’s sound operating position as well as that of the overall industry environment at this time. The increase is applicable to all plan options, however as a result of rounding differences a few variations exist. Please refer to Annexure Afor the 2012 contributions as well as the increased threshold levels on the Priority, Comprehensive and Executive plan options. Medical savings as a percentage of total contributions remained unchanged for 2012.
Discovery Health has reviewed their Adult Dependant Eligibility Criteria and as a result only the following dependants will qualify for the adult dependant contribution.
- spouses
- ex-spouses
- full-time students up to the age of 25 or
- financially dependent disabled child dependants.
All other adult dependants, e.g. parents, children over the age of 25 will be charged the same contribution as a principal member. This will lead to significant contribution increases for those members affected. Discovery Health will be communicating directly with all affected existing members as part of Discovery Health’s year-end member communication process. This communication will request that proof of eligibility should be returned to Discovery by the 9th December 2011this may include proof that the main member is responsible for the medical aid contributions (e.g. ex spouse/partner); registration documents recognised by law/custom (additional spouses); medical proof of disability (financially dependent disabled children) etc. Discovery Health will charge the principal member rate for these dependants and will only amend the contributions on the first of the month following the month in which proof has been received, i.e. no backdating or refunds will be granted. A copy of this proof must be provided to your FPA / payroll administrator for record purposes. Contributions for non eligible adult dependants will be deducted via payroll for existing dependants but no future non eligible adult dependants will be deducted via payroll.
BENEFIT CHANGES
The majority of benefits will increase in line with the contribution increase of 8.9%, however the benefit limits for prescribed medication, internal prosthesis and oncology remain unchanged. The limits for external medical appliances and devices will increase with surgical inflation.
HOSPITALISATION BENEFITS
Networks
Refer to Annexure C for the list of hospitals applicable to the KeyCare and Delta plan options. Please note that no changes were announced on the Delta Hospital Network however the KeyCare Hospital Network has seen the Moot Hospital (Pretoria) being removed and the Clinix Phalaborwa Private Hospital has been added. The KeyCare 2012 Day Surgery Network has also been extended.
Deductibles
Members participating on Priority plans should note that the defined deductibles for in-hospital procedures will range from R1750 to R8600 in 2012. Please refer to Annexure B for more details.
Members participating on Delta plans should note that the deductible has increasedto R4550 per planned hospital admission if you do not make use of the Delta network of hospitals (Refer to Annexure C).
You should take note of the increases in the deductibles, refer tablebelow, if you consider having in-hospital dentistry treatment during 2012:
Hospital / % change / Day Clinic / % increase2011 / 2012 / 2011 / 2012
Member younger than 13 / R1 200 / R1 300 / 8.3% / R600 / R650 / 8.3%
Memberolder than 13 / R3 000 / R3 300 / 10% / R2 000 / R2 200 / 10%
DAY-TO-DAY BENEFITS
Members participating on Core plans do not have access to day-to-day benefits. With the exception of the KeyCare Plus plan which offers limited benefits through network providers, all other plans provide day to day cover through the Medical Savings Account and Above Threshold Benefit (where applicable).
INSURED BENEFIT
This benefit extends day-to-day cover once funds in the Medical Savings Account are depleted. Discovery Health will cover consultations, as follows, provided you visit a general practitioner (GP) in the Discovery Health GP Network.
Plan / Single member / FamilySaver Plans / Classic and Coastal / 3 consultations / 6 consultations
Essential / 2 Consultations / 4 consultations
Priority, Comprehensive and Executive Plans / This GP benefit is unlimited on the above mentioned plans as long as the member goes to a GP in Discovery Health’s network. This benefit also covers pathology at specific network providers however your GP or specialist must request the tests by completing the Discovery Health pathology form (available on
THE ALLIED AND THERAPEUTIC BENEFIT
Discovery Health has redesigned the allied health benefits on the Executive, Comprehensive and Priority plans. The following limits will apply for allied and therapeutic services from 2012, subject to available funds in the Medical Savings Account and Above Threshold benefit:
Health Professional / 2011 Benefit / 2012 BenefitPsychiatrists / Covered as a specialist out-patient consultation, with no sub-limit
Registered counselors / Mental Health Benefit: R12 000 to R16 000 / Cover provided through the Allied and Therapeutic Benefit:
Executive / Comprehensive / Priority
Classic / Essential / Classic / Essential
M / R12 500 / R10 000 / R6 000 / R6 000 / R4 000
M+1 / R15 000 / R13 500 / R8 500 / R8 500 / R6 000
M+2 / R17 500 / R16 500 / R11 000 / R11 000 / R7 500
M+3 / R21 000 / R19 000 / R13 000 / R13 000 / R9 000
Psychometrists
Education Psychologists
Clinic Psychologists
Stoma sister / Home nursing benefit: R6 650 per family
Wound care sister
Registered nursing sister
Chiropractors
Homeopaths / Covered through the Above Threshold Benefit with no sub-limits
Podiatrists
Speech Therapists
Occupational Therapists
Physiotherapists
Please note that these changes are not applicable to the Saver, Core and KeyCare plans.
THE ALLIED AND THERAPEUTIC EXTENDER BENEFIT
This has been introduced to cater for members who meet specific clinical entry criteria andwho exceed the above limits. The benefit, available on application, will provide additionalcoverfor allied healthcare services for a list of serious conditions (e.g. Autism, Cerebral Palsy, Parkinsons Disease, Multiple Sclerosis, Muscular Dystrophy etc).
CHRONIC MEDICATION (PREFERRED PROVIDERS)
You have cover for a defined list of chronic conditions according to your plan choice; the medication for these conditions is subject to Discovery Health’s approved medicine list. If you take medication that is not available on Discovery Health’s medicine list there is a set monthly amount available to cover your medicine costs. Discovery Health will pay medicine up to the Discovery Health Medicine Rate. Chronic conditionsneed to be approved by Discovery Health in order for the condition to be covered from the Chronic Illness Benefit.
When you utlilize MedXpress, Discovery’s medicine delivery service, you will not be required to fund any delivery oradministration fees. Discovery’s qualified service agents can also advise you on the most cost-effectivealternatives and you will be charged at the Discovery Health Medicine Rate or less – minimisingco-payments. All major pharmacy chains, including Clicks, Dis-Chem and MediRite, as well as over 1200 community pharmacies are contracted to charge Discovery Health members at this rate.
DISCOVERY HEALTH MEDSAVER BENEFIT
From January 2012, you will qualify for up to 25% cash back on all schedule 1 and 2 medicines purchased from any Clicks store countrywide. You must activate the benefit on and complete a Vitality Check (screening tests) in the Vitality Pharmacy Network or at a Wellness Day. All spouses and/or adult dependants on the membership will need to complete a Vitality Check to earn 25% cash back at Clicks. The MedSaver cash back will be paid back into your DiscoveryCard™ or a nominated bank account on a monthly basis.The minimum amount that will be paid as a cashback benefit to you is R50. If the accumulated cashback is less than R50 the payment will be held until such time that it exceeds R50.
KEYCARE PLANS
The KeyCare income bands remain unchanged for 2012. As a result some members may move into a higher income bracket and thus experience an increase in excess of the 8.9%. For those members who experience an increase of greater than R200 per month, with respect to the Company subsidised family (member, spouse and two children), the Company will provide a special dispensation.
The casualty fee for ALL KeyCare casualty units for 2012 is R185, therefore the preferred casualty network falls away and the flat rate will apply at all KeyCare hospitals with a casualty unit.
Discovery Health has added additional day case procedures which will be covered through the enhanced KeyCare Day Surgery network. The details will be included in your Discovery plan information which will be distributed early in 2012.
Newexclusions applicable to KeyCare plans include arthroscopies, removal of varicose veins and bunions.
VITALITY AND KEYFIT BENEFIT
Refining the key Vitality benefits
From 1 April 2012, the number of compulsory gym visits will increase from 24 to 36 visits in a rolling 12 month period, which equates to 3 times a month. The penalty for not meeting the minimum requirement will reduce the monthly discount from 80% to 50% for members who joined the gym after 1 January 2011.
You will earn booster Vitality points, if the results of your Vitality Check and fitness assessmentare within the healthy range. If theresults are not within a healthy range, you will earn fewer points in 2012.
The Pick n Pay DiscoveryCard benefit has been integrated with the Pick n Pay Smart Shopper card. You will continue to receive up to a maximum of 25% cash back on your HealthyFood™ purchases, and will therefore no longer have the option to increase your savings to 75% by opting to have the cash back paid into the Medical Savings Booster.
The additional discount you receive for paying with your DiscoveryCard at Pick n Paywill be replaced with Smart Shopper points, depending on your Vitality status.
Building on the HealthyFood™ Benefit
Discovery Vitalityhas introduced the Clicks HealthyCare™and the Adidas HealthyGear™ Benefits.
HealthyCare™ Benefit / You can save up to 25% on all products in the HealthyCare™ Product range available from Clicks after activating the benefit and completing a Vitality Check (screening tests). The saving is in addition to the existing 5% to 15% Clicks Cash-back rewards you already receive depending on your Vitality status.HealthyGear™ Benefit / You can save up to 25% on Adidas active gear and sports equipment available at all Adidas Stores and Totalsport Stores after activating the benefit and completing a fitness assessment. The discount is also in addition to the existing Vitality partner discount at Totalsports of up to 20% depending on your Vitality status.
You also have access to thesocial networks, facebook and twitter for the information on the Vitality benefit. The process to register is as follows: Log onto on the Vitality drop down menu/scroll to the bottom of the page and click on the “interact with us” link with facebook or twitter.
If on facebook click the “like” button to join the page and if on twitter, once the page opens click on “follow”. You will then be subscribed and receive notifications from Discovery Vitality.
ONLINE TOOLS
Discovery Health has developed a range of toolsto guide you through the system and to identify when you can expect benefits to be reimbursed in full i.e.Hospital Advisor (used when going to hospital); MaPS Advisor (for visiting the doctor); Med Advisor (when buying medicine); Benefit Advisor (for day-to-day medical expenses).
HOW MUCH WILL YOUR COMPANY PAY TOWARDS YOUR MEDICAL AID?
Company Subsidy Policy
Remember, itiscompulsoryforyoutobelongto theCompany’sapprovedmedicalaidscheme unlessyouareadependantonyourspouseorpartnersmedicalaidscheme.
Inordertoassistyouinmeetingthecostsofyourmedicalaidcover,theCompanywillcontributetowardsthe costofyourmedicalaidcover(medicalaidsubsidy).
WhowilltheCompanySubsidise?
TheCompanywillsubsidiseaspecificamountforyourself(thePrincipalMember),onespouse/partnerdependantanduptoamaximumof2children.
Dependantsovertheageof21,whoarestudying,willbechargedbytheschemeatanadultdependantrate,buttheCompanywillonlyprovideasubsidyatthechildrate–aslongasproofofstudiesisprovided.
Thechildsubsidywillalsoonlyapplywhilstthechildisstudyinginatertiaryinstitution,andproofisprovidedassuch,butwillnotbeextendedbeyond25yearsofage. Physicallyormentallyhandicapped children, whoarereliantontheparentforsupport,mayqualifyforasubsidysubjecttoExecutiveapproval.
Children over the age of 21 who are not studying will be billed at a principal member rate, the Company does not subsidise these dependants.
HowMuchwilltheCompanySubsidise?
The Company subsidy has increased by 7.0% for all options
TheCompanysubsidyisdependentonyourfamilysizeandtheoptionthatyouchoose. ThetablebelowdepictstheCompanysubsidytable for 2012:
Plan Option / PM / SP / CD 1 / CD 2Core Options / R726 / R513 / R271 / R271
Executive, Comprehensive Priority and Saver Options / R821 / R574 / R327 / R327
KeyCarePlus
(R0 – R3900) / R375 / R356 / R102 / R102
KeyCarePlus
(R3901 – R6250) / R417 / R376 / R128 / R128
KeyCarePlus
(R6251 – R8300) / R556 / R501 / R155 / R155
KeyCarePlus
(R8301+) / R726 / R513 / R271 / R271
PM : Principal Member;
SP : Spouse
CD 1: Child Dependant 1
CD2: Child Dependant 2
GAP COVER INSURANCE – ADMEDGAP
The AdmedGap contribution will increase from R97 (2011) to R103 per family per month with effect from
1 January 2012. This is a voluntary membership and is payable directly from your bank account by debit order.
AdmedGap is a short term insurance policy that covers the difference between the doctors private costs (e.g. anaesthetists, surgeons, other specialists and GP’s) and the Admed Tariff for procedures done in hospital, subject to a maximum of four times the Admed Tariff. It is important to note that most medical schemes such as Discovery Health have adopted their own internal rates of reimbursement (internal tariffs) and that these may not necessarily agree with the Admed Tariff rate. The AdmedGap benefits will continue to be linked to the Cost of the Practitioner as it is not possible to set benefits that are linked to all the various internal tariffs adopted by the many medical schemes registered in South Africa.
No changes have been made to the policy benefits, exclusions and waiting periods for 2012. The policy limits have however been increased to R200 000 per insured person and R2 000 000 per family per calendar (policy) year. Details of the general exclusions and waiting periods can be obtained from Alexander Forbes Health or the Admed website on
An excess will be applicable to all claims in respect of claiming members who are 60 years of age or older. This excess will amount to 5% of the benefit payable, subject to a minimum of R250.00. All principal members of AdmedGap automatically qualify for Personal Accident cover amounting to R25 000.00.
Existing employees/medical scheme members who have not yet joined AdmedGap may join on 1January2012. An application form needs to be completed and can be obtained from your FPA / payroll administrator or on the healthcare website – refer page 1. Please use the Application for Debit Order Membership. Due to this option being voluntary, waiting periods and exclusions will apply.
Finally, we wish you good health in 2012!
Alexander Forbes Health Consultants and Actuaries
Live without regret.
Annexures
A – Standard 2012 Discovery Health rates
B – Priority Series - Deductibles
C – Delta and KeyCare Network of hospitals
D – Plan Option Change Form
Disclaimer: While all reasonable care has been taken by Alexander Forbes Health in compiling this communication, we have relied upon the accuracy and completeness of the information made available to us and subsequently cannot accept any liability or any errors or omissions that may arise as a result of the reliance of such information.
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ANNEXURE A - CONTRIBUTION TABLES
DISCOVERY HEALTH 2012
Total monthly contributions
Series / Plan / Principal Member / AdultDependant** / Child
Dependant *
Executive / Executive / 3 365 / 3 365 / 638
Comprehensive / Classic Comprehensive / 2 760 / 2 609 / 552
Classic Delta Comprehensive / 2 485 / 2 350 / 494
Essential Comprehensive / 2 320 / 2 191 / 463
Essential Delta Comprehensive / 2 088 / 1 972 / 417
Priority / Classic Priority / 1 850 / 1 457 / 740
Essential Priority / 1 590 / 1 249 / 635
Saver / Classic Saver / 1 652 / 1 300 / 660
Classic Delta Saver / 1 320 / 1 038 / 529
Essential Saver / 1 312 / 982 / 524
Essential Delta Saver / 1 049 / 787 / 418
Coastal Saver / 1 277 / 957 / 513
Core / Classic Core / 1 229 / 967 / 491
Classic Delta Core / 984 / 773 / 393
Essential Core / 1 056 / 791 / 422
Essential Delta Core / 844 / 633 / 339
Coastal Core / 892 / 669 / 356
KeyCare / KeyCare Plus (R8 301+) / 1 211 / 1 211 / 324
KeyCare Plus (R6 251 to R8 300) / 813 / 813 / 228
KeyCare Plus (R3 901 to R6 250) / 581 / 581 / 168
KeyCare Plus (R0 to R3 900) / 485 / 485 / 129
KeyCare Core (R8 301+) / 894 / 894 / 202
KeyCare Core (R6 251 to R8 300) / 579 / 579 / 144
KeyCare Core (R0 to R6 250) / 465 / 465 / 117
*Contributions are charged up to a maximum of 3 children