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Looking for the above threshold benefit but not willing to pay the price? Is this the answer?

But first a quick word about Priority…

This is 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 quite enjoy the unlimited above threshold benefit offered on the Comprehensive plans.

In other words, you run out of medical savings towards the end 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. That’s because Discovery Health picks up the tab for what’s left of the year.

If 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. For those on the Classic option, this benefit includes kid’s casualty visits.

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

For 2018, the cost of the Priority range increases with 8.29% for a single member on Classic and 8.31% on Essential.

So what do Priority plans have in common with the comprehensive plans?

Classic and Essential options offering two levels of cover

Just like the Comprehensive plan range, the Priority range offers a choice of 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 your tab.

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

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

That sound confusing even to me, so 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 R2,000 of 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 a cheaper cost.

Face it; the reason you’re choosing this type of plan is because of the above threshold benefit. So why punish yourself with a large 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 with the Priority range is that this above threshold benefit is capped. 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 Comprehensive 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.

  • 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 things:

  • 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 R3,900 (On the comprehensive range it’s R3,400) 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 R2,750 is paid from your day-to-day benefits.
If the treatment is for conservative back and neck treatment, then you can add a further R3,050 to the R2,750 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 the 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)R3,050
Myringotomy (grommets)R3,050
Functional nasal proceduresR7,300
Hysterectomy (except for pre diagnosed cancer)R7,300
Endometrial ablationR7,300
Nissen fundoplication (Reflux surgery)R15,000
Spinal surgeryR15,000
Joint replacementsR15,000

And 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 R16,300 per person (versus R26,200 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 – R2,200 upfront
  • Anyone older than 13 – R5,650 upfront

If it’s day clinic:

  • Children younger than 13 – R1,000 upfront
  • Anyone older than 13 – R3,650 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 buy a brand new pair of spectacles.

Discovery Health would pay R4,550 and you would need to pay the balance out of pocket.
That’s because on the Priority plan range, anything eye related is limited to R4,550 per person (versus R5,000 per person on the Comprehensive plans).

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

  • Classic plans – R19,000 per family (versus R23,700 per family on Comprehensive)
  • Essential plans – R13,500 per family (versus R19,000 per family on Comprehensive)

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

Single member:

  • Classic – R18,600 (R28,850 on Comprehensive), and
  • Essential – R 13,250 (R18,600 in Comprehensive)

Plus one dependant:

  • Classic – R22,600, and
  • Essential – R15,700

Plus two dependants:

  • Classic – R27,200, and
  • Essential – R18,550

Three or more dependents:

  • Classic – R29,700, and
  • Essential – R22,550

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)

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

If you missed some of our previous Discovery Health 2018 articles click on the links below:

  1. Choosing you plan
  2. Is KeyCare the right match for you
  3. The Executive plan
  4. The Comprehensive series

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