***DISCOVERY HEALTH 2017 – PART FOUR***

The Comprehensive Plans

Seriously wanting a good medical aid? Then seriously consider the Discovery Health Comprehensive range

It’s not quite at the level of the Executive plan which is part three of this series, but the differences are minuscule and possibly not worth the difference in cost.

If you missed the part where we discussed Discovery Health in general, click part one. For the part where we discussed KeyCare, click part two.

One thing I didn’t mention in part three was the increase in cost of the Executive plan.

For 2017, the cost of both the Executive plan and the Comprehensive range, increased by 11.9%. These are the steepest increases across the range barring Coastal Core which we’ll get to later.

And the reason for the steep increases?

Quite simple – Less healthy clients are migrating to the plans offering the most comprehensive cover. Discovery Health refers to this as demand-side pressure (You’ve just got to love the terminology, right? I’d have thought that it’s about the healthcare industry demanding more).

What does this mean for the healthier clients on Comprehensive?

Why pay more for cover you’re actually not using?

But be careful before downgrading:
Unlike Fedhealth who allow upgrades during the year if your health circumstances change, Discovery Health does not allow upgrades during the 12 month cycle.

So what do Comprehensive plans offer that the others don’t?

The first difference is chronic medication.

While the lower plans cover chronic medication for all 27 diseases appearing on the prescribed minimum benefits list (PMB’s), the comprehensive range covers additional chronic conditions.

It’s always a great idea, if you’re on chronic medication, to first check the medication on the plan you intend moving to. I’ve had clients jump onto one plan type – and then off – because the medicine their doctor prescribed wasn’t covered.

The next big difference is the unlimited above threshold benefit.

Quick recap…

Once you run out of day-to-day savings on any of the top three plan ranges – Executive, Comprehensive (except for the zero MSA plan), and Priority – you can make use of the Discovery Health day-to-day expenses benefit (DEBS) for things like unlimited GP consultations, kid’s casualty visits, and antenatal consultations.

And then there’s the self-payment gap which you have to work through for all your other expenses. Once you’ve crossed that gap, you end up in the above threshold benefit. On the Executive and Comprehensive ranges, this benefit is unlimited whereas on the Priority range it’s limited. On any plan lower than Priority it’s just a rumour. I discussed the self-payment gap in more detail in the Executive article.

The above threshold benefit is reached once your medical expenses exceed:

  • R15, 500 for each adult, and
  • R2, 950 for each child up to a maximum of three taken into consideration (The fourth child doesn’t increase the self-payment gap!)

A really big one is the oncology benefit.

I can’t stress this enough. If cancer treatment is vital in your family, then you need to be on either the Executive plan or any of the Comprehensive plans.
That’s because these plans offer up to R400, 000 of approved cancer treatment in every 12 month cycle. Anything costing more than R400, 000 in those 12 months will result in a 20% co-payment being levied.

On the lower plan ranges – Priority downwards – the level of cover drops to R200, 000 in every 12 month cycle. I’d recommend cancer specific gap cover regardless of your plan.

And finally there’s benefits exclusive to Executive and Comprehensive plans.

Trauma Recovery Benefit

This pays for out of hospital claims related to trauma in the year the trauma occurred as well as the year after.

Specialised Medicine and Technology Benefit

Pays up to R200, 000 per person for a list of the latest and most advanced treatments. A 20% co-payment applies (another reason for gap cover).

Overseas Treatment Benefit

R500, 000 per person for evidence based treatment not available in South Africa (I can see this becoming a major headache for them as time goes by). Once again a 20% co-payment applies (Gap cover?).

Additional cover for allied, therapeutic, psychology, and external medical items

Unlimited cover is available for services like physiotherapy, and illnesses such as quadriplegia, and cerebral palsy. Cover depends on the condition and meeting the criteria.

How to choose between Classic and Essential

Two things to consider:

  • The Classic plans offer 200% of the DHR for treatment in hospital by surgeons and their ilk. The Essential plans only offer 100% of the DHR for the same thing.
  • It’s also about the percentage going towards the Medical Savings Account (MSA). You see when it comes to hospital expenses and chronic medication, Discovery Health charges a basic risk premium. But to pay for your day-to-day doctor expenses, they offer you the MSA. On the Classic options the amount allocated to this is 25% of the total contribution. On the Essential plans this percentage reduces to 15% of the total contribution.

What should you watch out for on Comprehensive plans?

  • Scopes (Gastroscopy, colonoscopy, sigmoidoscopy, and proctoscopy)
  • MRI and CT scans (if not part of your reason for hospital admission or if done for conservative back and neck treatment)
  • The Discovery Health Rate

And why is that?

When it comes to scopes the first R3, 150 of your hospital account is paid from your day-to-day savings and the balance from your hospital benefit. On the Executive plan it’s the other way around – the hospital account is paid from your hospital benefit and the balance from your Medical Savings Account.

With scans, if it’s part of an approved in hospital treatment then it’s paid from your hospital benefit at 100% of the Discovery Health rate (and here you might want to think about gap cover to take care of any co-payment).

If the reason for the scan is either conservative back or neck treatment – or not related to the reason for your admission to hospital – the first R2, 900 is paid from your day-to-day benefits (or from your above threshold benefit if you’re on the Classic Zero MSA plan, and that’s only once you reach it. If you haven’t reached it, then you pay from your pocket).
The balance of your expense is then paid from the hospital benefit at 100% of the DHR.

While the Discovery Health Rate (DHR) might mention that those on any of the ‘Classic’ plans are covered at 200% of the DHR, that’s not an accurate picture.
Radiology and pathology are covered at 100% of the DHR across all Comprehensive plans.

And before I forget about teeth, eyes, ears, pills and wheelchairs

Nothing generates more complaints about medical aid than dentistry. There’s not much good news when it comes to dentist visits and orthodontics – it still comes out of your Medical Savings Account.

  • Basic dentistry has no overall limit BUT
  • The fitting and cost of dental appliances as well as orthodontic treatment is paid at 100% of the DHR, and
  • Limited to R25, 300 per person on your plan (or less depending on when you joined the scheme).

If we’re talking about dental treatment while in hospital, then it depends on whether you’re booked into a day clinic or hospital. Both involve upfront payments.
If it’s hospital:

  • Children younger than 13 – R2, 050 paid upfront
  • Anyone older than 13 – R5, 250 paid upfront

If it’s day clinic:

  • Children younger than 13 – R930 paid upfront
  • Anyone older than 13 – R3, 400 paid upfront

Spectacles generate the most confusion of all. Let’s say, for arguments sake, your Medical Savings Account has R5, 000 available, and you decide to use it to buy a brand new pair of spectacles.

Discovery Health would pay the full R5, 000 if you have enough MSA in your account, BUT the difference will get added onto your self-payment gap.
That’s because on the Comprehensive plan range, anything eye related is limited to R4, 600 per person on your plan. That means, on your R5, 000 invoice, R400 is added to your self-payment gap. If you were already in self-payment gap only R4, 600 would go towards closing the gap.

Hearing aids are handled differently. It works on an amount per family and type of plan:

  • Classic plans – R22, 900 per family
  • Essential plans – R18, 300 per family

Prescribed medicine is also limited when it comes to schedule 3 medicines and above.

Single member:

  • Classic – R26, 650, and
  • Essential – R17, 200

Plus one dependant:

  • Classic – R31, 300, and
  • Essential – R20, 850

Plus two dependants:

  • Classic – R36, 350, and
  • Essential – R25, 150

Three or more dependants:

  • Classic – R41, 450, and
  • Essential – R27, 450

I did mention wheelchairs but to be accurate it’s more than just wheelchairs and refers to all ‘external medical items’.
Much the same as hearing aids it’s about family and plan type:

  • Classic plans – R58, 800 per family
  • Essential plans – R39, 400 per family

I might have missed a point or two (such as the self-payment gap booby trap) but I think you get the gist of it. In part five we’ll take a look at the Classic Comprehensive plan.

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6 thoughts on “***DISCOVERY HEALTH 2017 – PART FOUR***

  1. Should you be on classic comprehensive and you have (Teeth) crowns done in the reagent of say R15000.00 then down grade or opt out of the fund after two months or so would the fund still pay the total amount or would you have to pay in some kind of a difference.