Discovery Health 2017 – Part 10

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Next we get to the Priority plan range from Discovery Health. This is similar to part four where we discussed the Comprehensive plan range in detail.

But first a quick word about Priority…

I think it’s a great option if you’re the kind of person who just makes it into the above threshold benefit every year and never gets to enjoy the unlimited above threshold benefit.

In other words, you run out of medical savings towards the middle of the year, climb out of the self-payment hole towards October, and end up just dipping into the above threshold benefit by November/December.

With the Comprehensive range the above threshold benefit is unlimited which is great if you’re through the self-payment gap by about June, and for the rest of the year Discovery Health picks up the tab.

Of course, while you’re in that self-payment gap, you can make use of the day-to-day Extender benefit, which among other things, allows you to see a networked GP as often as you need to.

But you also need to watch out for the large number of co-payments on Priority. If nasty surprises aren’t your thing, then read the fineprint on this one.

For 2017, the cost of the Priority range increases with 9.9%.

So what do Priority plans have in common with the ‘better’ plans?

Classic and Essential options offering two levels of cover

Just like the Comprehensive plan range, the Priority range offers a choice of either 200% or 100% of the DHR for in hospital treatment by specialists.
The Classic Priority plan offering 200% of the DHR while Essential Priority offers 100%.

The self-payment gap

These are also the last of the tricky plans. Tricky because they have a self-payment gap which you need to work through before Discovery Health will once more pick up the tab.

As is the case with the Classic and Essential Comprehensive plans; the self-payment gap on the Essential Priority plan is much wider than that of the Classic Priority plan.

I think this negates much of the benefit of the Essential Priority plan.
After all, you’ve chosen this plan because every year you seem to run out of MSA. But every year you just just make it into the above threshold benefit without using much of the unlimited above threshold benefit offered on the Comprehensive range.

Let me give you an example:
Let’s say you run out of MSA by May. You start paying your own medical bills to close the self-payment gap. By October you’ve closed the self-payment gap and are now into the above threshold benefit. You then end up only claiming a miserly R2, 000 from the above threshold benefit.

Now if I was on this plan, I’d want that self-payment gap to closes as soon as possible so I could get into the above threshold benefit. By choosing the Essential Priority plan, I’m essentially (I couldn’t resist that, sorry) choosing a bigger self-payment gap in exchange for the cheaper cost.

Face it; the reason you’re choosing this type of plan is because it offers an above threshold benefit. Why punish yourself with a larger self-payment gap?

The above threshold benefit

Quick recap…the Executive and Comprehensive range offer an unlimited above threshold benefit.

This is great if:

  • you’re the type of person who runs out of MSA by March,
  • who chomps through the self-payment gap by June, and
  • who dips deeply into the above threshold benefit

The difference between the Comprehensive and Priority range is that this above threshold benefit is capped on the Priority range. In other words, if you’re only dipping into the above threshold benefit at the end of the year, then this might be the plan for you.

Here is where the ‘better’ plans and the Priority range part ways

The first difference is for those on chronic medication.

Priority plans only cover chronic medication for the 27 diseases appearing on the prescribed minimum benefits list (PMB’s). The comprehensive range covers additional chronic conditions.

The oncology benefit
I’ve said this before. If cancer treatment is vital in your family, then you need to be on either the Executive plan or any of the Comprehensive plans.
On the Priority plan ranges the level of cover drops from R400, 000 to R200, 000 during every 12 month cycle.

And finally there are the benefits exclusive to Executive and Comprehensive plans.

  • Trauma Recovery Benefit
  • Specialised Medicine and Technology Benefit
  • Overseas Treatment Benefit
  • Additional cover for allied, therapeutic, psychology, and external medical items

What’s the big difference between Classic and Essential?

Two reasons:

  • 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, to cover hospital expenses and chronic medication, Discovery Health charges a basic risk premium. But to pay for your day-to-day expenses, they offer you the MSA. On the Classic options the amount allocated to this is 25% of the risk premium. On the Essential plans this percentage reduces to 15% of the risk premium.

What should you watch out for on Priority plans?

  • Scopes (Gastroscopy, cystoscopy, colonoscopy, sigmoidoscopy, and proctoscopy)
  • MRI and CT scans (if not part of your admission or if for conservative back and neck treatment)
  • The Discovery Health Rate, and
  • A barrage of co-payments

And why is that?

Well when it comes to the abovementioned scopes the first R3, 600 (On the comprehensive range it’s R3, 150) of your hospital account is paid from your day-to-day savings and the balance comes from your hospital benefit.

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 need gap cover to take care of any shortfall).

If the reason for the scan is not related to your admission – the first R2, 900 is paid from your day-to-day benefits.
If the treatment is for conservative back and neck treatment, then you can add a further R2, 800 to the R2, 900 mentioned above.
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 only covered at 100% of the DHR on Priority plans.

Let’s chat about co-payments for a moment

If at any time you book into hospital for any of the following, an upfront payment will need to be made to the hospital. So be careful if you’re aware that you’ll be undergoing any of these procedures in the year ahead.

Conservative back and neck treatment (I mentioned this above)R2, 800
AdenoidectomyR2, 800
Myringotomy (grommets)R2, 800
TonsillectomyR2, 800
ArthroscopyR6, 750
Functional nasal proceduresR6, 750
Hysterectomy (except for pre diagnosed cancer)R6, 750
LaparoscopyR6, 750
HysteroscopyR6, 750
Endometrial ablationR6, 750
Nissen fundoplication (Reflux surgery)R13, 850
Spinal surgeryR13, 850
Joint replacementsR13, 850

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

Nothing generates more complaints 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 R15, 750 per person (versus R25, 300 per person on the comprehensive range) on your plan or less depending on when you joined the scheme.

If it’s dental treatment while in hospital that we’re talking about, then it depends on whether you’re booked into a day clinic or hospital. That’s because a visit to either involves upfront payments.

If it’s hospital:

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

If it’s day clinic:

  • Children younger than 13 – R930 upfront
  • Anyone older than 13 – R3, 400 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 but add an amount of R800 to your self-payment gap.
That’s because on the Priority plan range, anything eye related is limited to R4, 200 per person (versus R4, 600 per person on the Comprehensive plans).

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

  • Classic plans – R18, 300 per family (versus R22, 900 per family on Comprehensive)
  • Essential plans – R13, 000 per family (versus R18, 300 per family on Comprehensive)

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

Single member:

  • Classic – R17, 200 (R26, 650 on Comprehensive), and
  • Essential – R 12, 250 (R17, 200 in Comprehensive)

Plus one dependant:

  • Classic – R20, 850, and
  • Essential – R14, 500

Plus two dependants:

  • Classic – R25, 150, and
  • Essential – R17, 150

Three or more dependants:

  • Classic – R27, 450, and
  • Essential – R20, 850

Regarding ‘external medical items’
Much the same as hearing aids in that it’s about family and plan type:

  • Classic plans – R39, 400 per family (R58, 800 per family on Comprehensive)
  • Essential plans – R26, 450 per family (R39, 400 per family on Comprehensive)

I might have missed a point or two but I think you get the gist of it. In the next part we’ll take a brief look at the Classic Priority plan.

Here’s links to all the Discovery Health 2017 articles:

  1. Part one – Discovery Health in a nutshell
  2. Part two – Where does KeyCare fit in?
  3. Part three – The Executive plan
  4. Part four –  The Comprehensive range
  5. Part five – The Classic Comprehensive plan
  6. Part six – The Classic Delta Comprehensive plan
  7. Part seven – The Classic Comprehensive Zero MSA plan
  8. Part eight – The Essential Comprehensive plan
  9. Part nine – The Essential Delta Comprehensive plan

< Do you need assistance with your medical aid?

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Until next time.

The InsuranceFundi Team

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