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SA's No 1 Insurance Blog

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Today we tackle the big daddy at Discovery Health…their Executive plan.

That’s right; if you want the best that Discovery Health can offer, then this is the plan for you.
For most it’s overkill, especially when compared it to the Discovery Health Classic Comprehensive plan which is more than enough for most of us.

But if you’re only joining the conversation now, you might want to check out part one where we discussed Discovery Health in a nutshell, and part two where we looked at where KeyCare fits into the picture.

Let’s take a look at what the Executive plan has that the other plans don’t.

In part one of this series I discussed the Discovery Health Rate (DHR). The minimum Discovery Health would generally pay for a procedure is 100% of their rate (I did notice they drop down to 90% of the Discovery Health Rate when it comes to non-preferred medicine).

On the Executive plan they bump you up to 300% of the Discovery Health Rate. What this means is that when it comes to seeing specialists while in hospital, Discovery Health will pay up to three times their standard rate – that’s 100% more than their next best plan.

But be careful – not everything is covered at 300%:

  1. Other healthcare professionals are covered at 100% of the DHR
  2. Radiology and pathology benefits are also covered at only 100% of the DHR.

Then there’s the exclusive list of brand name medicines available under the chronic medication benefit.

Furthermore, while in hospital Discovery Health cover up to R1, 750 per day in a private ward. On all the other plans it’s general ward cover only.

And finally there’s the lack of self-payment gap on this plan.
In other words, when your medical savings account (MSA) runs dry, you jump straight into the above threshold benefit which has no ceiling.

A word of caution though – don’t think for a moment think you can’t create your own self-payment gap.

I don’t want to get too technical in this article, but Discovery Health get very iffy when you buy:

  • schedule 0-2 medication, as well as
  • schedule 3 and above medications from the non-preferred medicine list

with your medical savings account (MSA).
Non-preferred simply means medicines which, according to Discovery Health, are too costly versus their effectiveness.

When it comes to non-preferred medicines, Discovery Health will only count 90% of the DHR towards the above threshold benefit. The remaining 10% becomes a self-payment gap once you run out of MSA. By the way, this is the only plan which offers 90%. The lower plans work on a 75%/25% split.

Medicines on the preferred medicine list are paid at 100% of the DHR but be warned that if the pharmacy you choose charges more than the Discovery Health rate, the amount overcharged will create a self-payment gap.

So while they’ll pay for it (if you have MSA available), they’ll also add it onto your self-payment gap. It’s a “we’ll pay now but you’ll pay later” scenario.

And this applies to the above threshold benefit as well…
Anything over-the-counter (schedule 0-2) will be for your pocket.

Schedule 3 and above medications from the non-preferred medicine list will mean you’ll find yourself having to pay in every time you fill a script.
And if the pharmacy you decide to use charges more than 100% of the DHR; you’ll end up paying the difference. That’s why it’s important to use:

  • MedXpress
  • Dischem, or
  • Clicks

So who’s a good match for this plan?

Well first of all it’s not cheap at R5, 544 for adults and R1, 055 for children. A husband and wife combo would cost R11, 088 a month.
Compare that to their next best plan – Classic Comprehensive at R8, 770 a month for the same couple.

The 300% of the Discovery Health Rate is not a biggie since you can always take out medical gap cover and bump even the lowest plan offering only 100% of the Discovery Health Rate right up to 500% of the Discovery Health Rate. Speak to me about this if you’re interested in gap cover.

This plan is definitely for those with higher than average medical costs.
I’m thinking of a person needing a number of MRI and CT scans done in the coming year. All of these are paid out of your day-to-day savings on this plan. And don’t forget scopes. A portion of any scope done while in hospital is also paid out of your day-to-day savings.

I also noticed that the overall limit for dentistry is R48, 350 per person on all dental accounts. If you join later in the year then this benefit is reduced accordingly.
On the Comprehensive plan range basic dentistry is unlimited, BUT appliances and orthodontics are limited to R25, 300 per person and are paid from day-to-day benefits. Treatment in hospital on these plans also requires that certain amounts be paid upfront upon admission.

So dentistry is another plus point for the Executive plan.

The other big question is oncology.

Cancer is becoming more and more prevalent and it’s important to note that not all Discovery Health plan ranges offer the same level of cancer cover.

The Executive plan has this in common with the Comprehensive plan range in that it pays the first R400, 000 of approved cancer treatment during a 12 month cycle.
If you use more than R400, 000 during every 12 months a 20% co-payment applies. There are gap cover products available on the market which will take care of this.

What else is only available on the Executive and Comprehensive plan ranges?

Four that you need to know of:

  • Trauma recovery extender benefit
  • Specialised medicine and technology benefit
  • Overseas treatment benefit, and
  • Cover for allied, therapeutic, psychology, and external medical items

Trauma recovery and extender benefit
This pays out of hospital claims related to trauma in the current year as well as the following year.

Specialised medicine and technology benefit
This pays up to R200, 000 per person for a list of the latest treatments. It comes standard with a 20% co-payment

Overseas treatment benefit
This pays up to R500, 000 per person for evidence based treatment not available in South Africa. A 20% co-payment also applies. By evidence I assume it means that “there must be evidence that this overseas procedure works”.

Cover for allied, therapeutic, psychology, and external medical items
This offers unlimited cover for things like physiotherapy, quadriplegia and cerebral palsy.

I almost forgot about spectacles, pills, ears, and wheelchairs

When it comes to eyes, this plan offers the highest benefit of all:

  • R6, 800 per person (versus R4, 600 per person on the Comprehensive plan range)

But this doesn’t mean that just because you have R20, 000 available in your medical savings account, that Discovery Health will pay for your R10, 000 pair of designer shades. The maximum they’ll pay for each person is R6, 800 – and you might need to motivate why they should pay the difference. That difference will form part of your self-payment gap.

Prescribed medicine (schedule 3 and above) is limited as follows:

  • Single member – R33, 000 (versus R26, 650 on the Classic Comprehensive plans)
  • Member plus one – R38, 700
  • Member plus two – R44, 300
  • Member plus three or more – R49, 950

Over-the-counter medicines are paid from your medical savings account only. These don’t count towards your self-payment gap and aren’t paid from the above threshold benefit.

For the hard of hearing, R22, 900 is available for hearing aids for the family. This is the same as the Comprehensive plan range.

For anyone requiring external medical items such as wheelchairs – the annual limit is R58, 800 for the family. This is also the same as the Comprehensive plan range.

Financially, which makes more sense – Executive or Classic Comprehensive?

Main member onlyExecutiveClassic ComprehensiveDifference
Monthly costR5, 544R4, 506R1, 038
Annual MSAR16, 632R13, 512R3, 120
Self-payment gapR1, 988
Total annual costR66, 528R56, 060R10, 468

If one has to take the annual cost of the Classic Comprehensive plan, and add to that the self-payment gap amount of R1, 988, we can see that there’s a difference in cost of R10, 468 over a year. Add this difference to the annual medical savings account offered on the classic comprehensive plan, and you suddenly have R23, 980 available for day-to-day expenses (R13, 512 + R10, 468).

The accountant in me says “go with the Classic Comprehensive plan”. Not sure what your inner accountant is saying?

I think we’ve hit all the major bases in this article. In the next article we take a bird’s eye view look at the Comprehensive plans.

Do you need assistance with your medical aid?

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Until next time.

The InsuranceFundi Team


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