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SA's No 1 Insurance Blog

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In part thirteen we did a broad overview of the Saver range. Think of the Core range as a ‘Saver’ plan without the savings. Which raises the question: “Why go for a plan where you’re not going to save?” Stay with me here.

The most often asked question I get is: “I’m just looking for a hospital plan.”
The problem with that question is: “Would that be a short term insurance hospital plan or would that be a medical aid hospital plan?” Today we’re looking at a medical aid hospital plan.

By the way…
I haven’t mentioned this before, but one advantage to the plans offering you a medical savings account, is that you get to accumulate the savings year after year. The savings does not fall away at the end of each year.

And if you’re wondering whether you can ever get your hands on your medical savings account…

No, unless you don’t intend to join another medical scheme. It either gets transferred to your new scheme or it gets paid back to you after four months.
But don’t wait out the four months if you intend to join another scheme later. After a 90 day gap of non-membership, a scheme is entitled to apply waiting periods before allowing you to claim.

So what kind of price increase can you look forward to in 2017 on the Saver range?

Four of the five plans have a 9, 9% increase while the Coastal Core plan has a nasty 14, 9% increase.
That’s because, according to Discovery Health, a bunch of new hospitals sprang up in the coastal provinces creating increased demand. Apparently admission rates on the Coastal plans have increased by 23%. So much for the relaxed lifestyle at the coast it seems!

So where do Core plans differ from the other plans?

For those on chronic medication

Chronic medication is offered for all 27 diseases appearing on the prescribed minimum benefits list (PMB’s).
On the Core options, you need to get your medicine from Discovery themselves via the MedXpress service or MedXpress partner pharmacies. If you use someone else for your chronic medication then a 20% co-payment will apply.

There is no medical savings account or above threshold benefit.

You pay all your own day-to-day expenses. Spectacles, dentists, doctors, and medicines all come out of your pocket.

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 Core plan ranges the level of cover drops to R200, 000 in every 12 month cycle.

Scopes

With the Core range, the amount you need to pay is R3, 900 for 2017. Compare this to R3, 150 on the Comprehensive range and R3, 600 on the Priority range when deciding.

MRI and CT scans

The good news is that these are paid from the hospital benefit in full IF related to an approved admission. If not related to your admission, or because of conservative back and neck treatment, then Discovery Health does not pay a cent.

What’s the big difference between Classic, Essential, Coastal, and Delta?

  • The Classic plans offer 200% of the DHR for treatment in hospital by surgeons. The Essential and Coastal plans only offer 100% of the DHR for the same thing.
  • Classic and Essential plans allow you to use a private hospital of your choice.
  • Delta means you need to use a hospital in the Delta network except in the case of an emergency. Failure to use a Delta hospital means you’d need to pay the hospital R7, 100 upfront prior to admission.
  • Coastal means you need to use any one of the selected private hospitals in the four coastal provinces. Be careful here; not all hospitals in the coastal provinces qualify as such. If you were to have a procedure done in Gauteng, for instance, then Discovery Health will only pay 70% of your bill. This doesn’t apply in an emergency.

What about your teeth?

Dentistry
All basic dentistry is paid by you. If it’s severe dental or oral surgery authorisation from Discovery Health needs to be obtained before undergoing the procedure.
On the Core range all dental appliances and the fitting thereof are paid by you.

There are upfront payments for anything done while in hospital. It depends on whether you’re booked into a day clinic or hospital.
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

The balance is paid from your hospital benefit at 100% of the DHR. On Classic plans they will pay the anaesthetist at 200% of the DHR.
Interesting fact: the major portion of in hospital specialist costs relate to anaesthetists.

Part of the hospital benefit includes the following:

  • Cochlear implants – R207, 000 per person
  • Internal nerve stimulators – R142, 200 per person
  • Shoulder joint prosthesis – no limit if you use their supplier. If you use your own supplier then this is limited to R40, 000 per prosthesis.
  • Major joints surgery – Paid in full if you use their supplier or at 80% if you use your own supplier
  • Alcohol and drug rehab – 21 days per person
  • Prosthetic devices used in spinal surgery – no limit if you use their provider. If not, then Discovery will cover R25, 500 for the first level and R51. 000 for two or more levels. This is limited to one procedure per person
  • Mental health – 21 days admission or 15 out of hospital consultations per person for things like bulimia and anorexia. Anything stress related is limited to 12 out of hospital consultations.
  • Chronic dialysis – Paid in full if approved and where their provider is used. If you go anywhere else then Discovery will only pay 80% of the DHR.

Prevention and Screening benefits

I haven’t really discussed these benefits in previous articles, but they are important since these tests are free at Discovery providers.
Things like:

  • Blood glucose
  • Blood pressure
  • Cholesterol
  • Body mass index (BMI)
  • HIV screening
  • Mammogram once every two years
  • Pap smear once every three years
  • Prostrate test every year, and
  • A whole bunch of kid’s growth assessment tests. Things like height, weight, and head circumference.

I know this all seems confusing, so if you only want to read the pillar articles relating to Discovery Health 2017, then click on the links below:

If you’d like to drill down in more detail, here are the links to each and every plan:

Do you need assistance with your medical aid? Drop us a line.

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Until next time.

The InsuranceFundi Team

 

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