Discovery Health 2017 – Part 12

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In part ten of this series we gave you the big picture view of the Priority range. The biggest issue by far was the number of co-payments on this range.
Other concerns were the self-payment gap and the limited above threshold benefit.

In the case of the Essential Priority plan, this is even trickier.

The Discovery Health rate

The Essential Priority plan offers 100% of the DHR for treatment by medical professionals while in hospital.
We don’t think 100% will cover you in full. (And 200% on the Classic Priority plan is not enough either).

The hospital bill itself gets paid at 100% of the DHR and hospital coverage is unlimited.
Unlimited means your in hospital costs for the year have no ceiling.

The amount going to your Medical Savings Account

15% of your contribution goes towards the medical savings account.  This has two disadvantages and one advantage:

  • A smaller MSA
  • A bigger self-payment gap, and
  • A cheaper cost

Let’s start off with the cost:

  • Main member – R2, 551 monthly
  • Adult dependants – R2, 004
  • Children – R1, 017 (A maximum of three children are charged for)

This gives us the following MSA for the year:

  • Main member – R4, 584
  • Adult dependants – R3, 600
  • Children – R1, 824 (A maximum of three children are used in this calculation)

Word of warning:
Remember this is a line of credit. If you join halfway through the year, then you get half the amount. If you decide to leave Discovery Health halfway through the year – and in between you’ve used up all of your MSA – then you’ll have to pay back half of the MSA allocated to you.

This brings us to the above threshold benefit
The above threshold benefit is the hurdle you need to reach before Discovery Health starts picking up the bills after having run out of MSA.

  • Main member – R13, 150
  • Adult dependants – R9, 850
  • Children – R4, 300 (A maximum of three children are used in this calculation)

But here’s how the above threshold benefit on the Priority range works.

It’s limited. Once you reach this limit you will once again have to pay your own bills. So if you’re someone who digs deep into the above threshold benefit every year, this ain’t the plan for you.

Let’s take a look at the amounts available once you’re in the above threshold benefit:

  • Main member – R11, 150
  • Adult dependants – R7, 950
  • Children – R3, 850 (A maximum of three children are used in this calculation)

So let’s look at how the self-payment gap works for the main member:

  • Main member MSA for the year – R4, 584
  • Main member above threshold benefit – R13, 150
  • The difference between the two is your self-payment gap – R8, 566
  • The amount available once you’re above threshold – R11, 150

Here’s how it compares to the Classic Priority:

Classic PriorityEssential PriorityDifference
Main member costR2, 968R2, 551R1, 038
MSA R8, 904R4, 584R3, 120
Annual ThresholdR13, 150R13, 150R1, 100
Self-payment gapR4, 300R8, 566R1, 988
Above Threshold BenefitR11, 150R11, 150

With a self-payment gap that size on the Essential Priority plan, and the small difference in cost, I’m sticking to the Classic Priority option.

Your potential self-payment gap could also be much bigger:

  • Schedule 0-2 medicines obtained via prescription or any means, are added to the self-payment gap even if paid from available MSA
  • Schedule 3 and above medicines from the non-preferred medicine list are only included at 75% of the DHR. The remaining 25% of the DHR is added onto your self-payment gap.
  • Schedule 3 and above medicines from the preferred medicine list are paid at 100% of the DHR but be careful since the pharmacy you use might charge more than the Discovery Health Rate thereby creating a self-payment gap. Use Dischem or Clicks or the Discovery MedXpress service to minimise this.
  • You overspend on spectacles and dentistry. For instance, on the Priority range your annual limit for spectacles is R4, 200 per person. You purchase a pair for R5, 000 thereby adding R800 to your self-payment gap.

Remember to keep sending your medical bills to Discovery Health while in self-payment gap – how else will they know whether the gap is closing?

Next we’re going to study the Saver range which is the last to offer you a medical savings account.  From here on in, self-payment gaps and above threshold benefits fall away.

And if you’re looking for our other 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
  10. Part ten***The Priority range***
  11. Part eleven – The Classic Priority plan

Do you need assistance with your medical aid?

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Until next time.

The InsuranceFundi Team

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