2014 - IBM Induction Presentation

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IBM Induction Presentation – Discovery Health
Presented by Nkosinathi Siyoko
Agenda
AF Health’s commitment to you
FAIS requirements
Discovery Health product range
Vitality
AF Health’s commitment to you
 We provide:
 Assistance in choosing the correct medical scheme option,
based on your needs
 Clarification of benefits and the escalation of any unresolved
medical scheme queries
 Liaison with your medical scheme on your behalf to ensure you
are treated fairly and correctly, based on your benefit
entitlements.
 To your employer we provide:
 Industry updates that could affect your business and members
 Strategic consulting to the employer.
FAIS requirements
 Alexander Forbes Health is an approved Financial
Services Provider – FSP 33471
 Alexander Forbes Health is accredited by the Council for
Medical Schemes – ORG 3064
 All information provided in this presentation is factual
and NO advice is provided
 General Disclosure and Product Supplier Disclosures
are available upon request
 Alexander Forbes Health are appointed brokers to
administrators and open medical schemes (actuarial and
consulting services).
Agenda
AF Health’s commitment to you
FAIS requirements
Discovery Health product range
Vitality
Discovery Health product range
Comprehensive
Classic/ Essential
200%/ 100%
Chronic: 61
MSA: 0%/15%/
25%
Threshold
Priority
Classic/ Essential
200%/ 100%
Chronic: 26
MSA: 15%/25%
Limited
Threshold
Saver
Classic/
Essential/
Coastal
200%/100%
Chronic: 26
MSA: 15%/25%
Core
Classic/
Essential/
Coastal
200%/100%
Chronic: 26
No MSA
Keycare
Plus/ Core/
Access
100%
Chronic: 26
Networks
Primary care
Discovery Health product range
 THE DELTA PLAN RANGE
Comprehensive
Saver
Core
10% premium
reduction
20% premium reduction
Discovery Health product range
 THE DELTA HOSPITAL NETWORK
Western Cape
Cape Town Medi-Clinic
Claremont
Kingsbury
Mitchells Plain
Panorama
Vergelegen
Plus 13 day clinics
Johannesburg
Arwyp
Bedford Gardens
Brenthurst
Carstenhof
Clinix – Lesedi
Clinix - Sebogeng
Clinton
Emfuleni
Fourways
Lenmed
Morningside
Robinson
Roseacres
The Donald Gordon
Wilgeheuwel
Plus 10 day clinics
Vaal
Midvaal
Suikerbosrand
Plus 6 day clinics
Pretoria
Bougainville
Legae
Little Company of Mary
Louis Pasteur
Plus 8 day clinics
Bloemfontein
Life Rosepark
Universitas
Plus 3 day clinics
Durban
Chatsmed
Entabeni
Ethekwini
Westville
Plus 1 day clinic
Pietermaritzburg
Midlands
Eastern Cape
Life New
Mercantile
Deductible of R5 450 if non-Delta hospital used
Med XPress must be used for chronic medication, or 20% co-payment
Discovery Health product range
 THE CORE SERIES
Hospital Benefit
• Covers approved hospitalization with no overall
limit
• Full cover when using specialist in one of DH’s
Direct Payment Arrangements
• MRI on Back and neck surgery not covered
Chronic Illness Benefit
• Cover for 26 conditions
•Subject to formulary or
lower Chronic Drug Amount
•
Preventive Screening Benefit
• VitalityCheck and other screenings
Discovery Health product range
Member
Main
Member
Spouse/
Adult
Dependant
Child
Dependant
Classic
Core
Classic
Delta Core
Essential
Core
Essential
Delta Core
Coastal
Core
R1 471
R1 177
R1 263
R1010
R1 087
R1 157
R925
R947
R757
R815
R587
R471
R506
R405
R434
Discovery Health product range
 THE SAVER SERIES
Hospital Benefit
• Covers approved hospitalisation with
no overall limit
• Full cover when using specialist in
one of DH’s direct payment
arrangements
Chronic Illness Benefit
• Cover for 26 conditions
•Subject to formulary or
lower Chronic Drug Amount
Preventive Screening
Benefit
• VitalityCheck and other
screenings
NO Above Threshold Benefit
Insured Network Benefit
GP’s
Single
Family
Classic & Coastal
3 visits
6 visits
Essential
2 visits
4 visits
Maternity Benefit
Classic Plans
8 antenatal consults
two 2D scans
Medical Savings
Account
• Pays day-to-day
medical costs
• Full annual deposit
available
up front
• Classic: 25%
• Essential 15%
• Coastal: 25%
Discovery Health product range
Member
Main
Member
Spouse/
Adult
Dependant
Child
Dependant
Classic
Saver
Classic
Delta
Saver
Essential
Saver
Essential
Delta
Saver
Coastal
Saver
R1 976
R1 578
R1 570
R1 254
R1 556
R1 556
R1 244
R1 175
R 942
R1 166
R790
R633
R628
R502
R625
Discovery Health product range
 THE PRIORITY SERIES
Hospital Benefit
• Covers approved hospitalization with no
overall limit
• Full cover when using specialist in one of
DH’s direct payment arrangements
Above Threshold Benefit (ATB)
• Limited ‘safety-net’ for day-to-day expenses
• Paid by Discovery at the DH Rate once
day-to-day claims reach certain level
Threshold 2014
ATB Limits
PM: 9 990
PM: 8 500
Adult: 7 510
Adult: 6 050
Child: 3 270
Child: 2 920
Defined procedures attract deductibles
Chronic Illness Benefit
• 26 conditions (CDL)
• Subject to formulary or
lower Chronic Drug Amount
Preventive Screening Benefit
• VitalityCheck and other
screenings
Insured Network
Benefit
• GP through network
during SPG
• Pathology at DSP on
Classic option
• Maternity Benefit on
Classic option
• Defined list of External
Medical items on
Classic & Essential
Medical Savings Account
• Classic: 25%
• Essential 15%
Discovery Health product range
 THE PRIORITY SERIES
 The Priority Plan has deductibles applicable to the
following procedures:
Deductibles
Conservative back and neck treatment, myringotomy
(grommets), tonsillectomy, adenoidectomy
2014
R2 150
Colonoscopy, Proctoscopy, Sigmoidoscopy, Gastroscopy,
Cystoscopy
R2 850
Arthroscopy, functional nasal procedures, hysterectomy,
endometrial ablation, Laparoscopy
R5 150
Reflux surgery, spinal surgery (back and neck) surgery and
joint replacements
R10 500
Discovery Health Product Range
 THE THRESHOLD LEVELFOR 2014 = R11,350
Discovery Health pays for claims from the ATB

‘Automatic’ SPG = R1,270
AT COST
GP Consultation (Network) – R320
Increase SPG
To R4,673
RATE OF ACCUMULATION
•Non-Premier Rate Specialist
•Consultation (DH Rate) + R520
Non -preferred Medicine List Medication
- R852
OTC medication (S 0,1 or 2) + R0
Premier Rate Specialist Consultation
- R498
(Non-network) Glasses + R3,500
Glasses – R5,780
Claims
X-rays (DH Rate) + R1,200
accumulated
Premier Rate
=Specialist
R6,677Consultation
OTC Medication (S 0, 1 or 2) – R630
Non –preferred Medicine List Medication
+ R639
•Non-Premier Rate Specialist
GP consultation (Network) + R320
X-rays
– R1,200
=R
0
+ R498
•Consultation – R800
• Based on a single member on the Classic Comprehensive Option
• Rates are examples
MSA for the year : R10,080
Additional enhancements to www.discovery.co.za
The Self-payment Gap tracker
The SPG Tracker provides detailed
information on what has contributed
towards the Self-payment Gap, without
the need to request this information
through a different channel
Available online
from January
2014
Discovery Health product range
Member
Classic Priority
Essential Priority
Main member
R2 254
R1 937
Spouse/adult dependant
R1 774
R1 522
R902
R774
Child dependant
Discovery Health product range
 THE COMPREHENSIVE SERIES
Hospital Benefit
• Covers approved hospitalization with
no overall limit
• Full cover when using specialist in one
of DH’s direct payment arrangements
Chronic Illness Benefit
• Cover for 61 conditions
(27 CDL & 34 ADL)
Preventive Screening
Benefit
• VitalityCheck & other
screenings
Above Threshold Benefit (ATB)
• Unlimited ‘safety-net’ for day-to-day
expenses subject to certain sub-limits
• Paid by Discovery at the DH Rate once
day-to-day claims reach certain level
Threshold 2014
PM: 11 350
Adult: 11 350
Child: 2 150
Insured Network Benefit
• GP, External medical
items – all options except
Classic Comp Zero MSA
• Maternity, Pathology &
Generic Meds (Formulary)
– On Classic & Classic
Delta
• DSP Applies
Medical Savings Account
• Classic: 25%
• Essential 15%
• Zero 0%
Discovery Health product range
 THE EXECUTIVE PLAN
Hospital Benefit
• Covers approved hospitalization with
no overall limit
• Specialists in hospital paid up to
300% of the DH Rate from MSA/ATB
• Private ward cover R1 400 per day
Chronic Illness
Benefit
• Cover for 61
conditions
(27 CDL & 34 ADL)
• Additional Medicines
covered
Preventive Screening
Benefit
• VitalityCheck & other
screenings
Above Threshold Benefit (ATB)
• Unlimited ‘safety-net’ for day-to-day
expenses subject to certain sub-limits
• Paid by Discovery at the DH Rate once
day-to-day claims reach certain level
Threshold 2014
PM: 12 300
Adult: 12 300
Child: 2 300
Insured Network
Benefit
• GP, Pathology, PML,
External medical
items & Maternity
benefit 100% cost
through network during
SPG
Medical Savings Account
• Minimal gap between MSA
and ATB
• Specialists covered up to
300% of Discovery Health
rate
Discovery Health product range
Member
Main
Member
Spouse/
Adult
Dependant
Child
Dependant
Executive
Plan
Classic
Comp
Classic
Delta
Comp
Essential
Comp
Essential
Delta
Comp
Classic
Zero MSA
R4 100
R3 362
R3 028
R2 825
R2 544
R2 522
R4 100
R3 180
R2 864
R2 670
R2 403
R2 385
R778
R670
R602
R568
R509
R503
Discovery Health product range
 CHRONIC ILLNESS BENEFIT (PMBs)
1
Addison’s disease
14
Epilepsy
2
Asthma
15
Glaucoma
3
Bronchiectasis
16
Haemophilia
4
Bipolar Mood Disorder
17
HIV/AIDS
5
Cardiac Failure
18
Hyperlipedaemia (High Cholesterol)
6
Cardiomyopathy
19
Hypertension (High Blood Pressure)
7
Chronic Obstructive Pulmonary
Disease (Emphysema)
20
Hypothyroidism (Inactive Thyroid Gland)
8
Chronic Kidney Disease
21
Multiple Sclerosis
9
Coronary Artery Disease
22
Parkinson’s Disease
10
Crohn's disease
23
Rheumatoid Arthritis
11
Diabetes Insipidus
24
Schizophrenia
12
Diabetes Mellitus (Type 1 & 2)
25
Systemic Lupus Erythomatosis
13
Dysrhythmia (Irregular Heartbeat)
26
Ulcertative Colitis
Discovery Health product range
 CHRONIC ILLNESS BENEFIT –
Comprehensive and Executive plans only
1
Ankylosing spondylitis
18
Paget’s disease
2
Behçet’s disease
19
Panic disorder
3
Connective tissue disorder (mixed)
20
Paraplegia
4
Cushing’s disease
21
Pemphigus
5
Cystic fibrosis
22
Peripheral arteriosclerotic disease
6
Delusional disorder
23
Pituitary microadenomas
7
Dermatopolymyositis
24
Polyarteritis Nodosa
8
Generalised anxiety disorder
25
Post traumatic stress disorder
9
Huntington’s disease
26
Psoriatic arthritis
10 Hypoparathyroidism
27
Pulmonary interstitial fibrosis
11 Major depression
28
Quadriplegia
12 Motor neurone disease
29
Sjögren’s syndrome
13 Muscular dystrophy and other inherited myopathies*
30
Stroke
14 Myasthenia gravis
31
Systemic sclerosis
15 Obsessive compulsive disorder
32
Thrombocytopaenia purpura
16 Organ transplantation
33
Valvular heart disease
17 Osteoporosis
34
Wegener’s granulomatosis
MedXpress delivers your medication to your door
What does it
cover?
Why should
members use it?
How does a
member use it?
MedXpress delivers medicine directly to members at no extra
cost
Acute
Chronic
Locations
delivered
Major Metropolitan
areas*
Countrywide
Time to delivery
6 hours**
72 hours
Convenience for members
Delivery to your door, Simple process with no forms, Delivery
tracking, Regular updates on changes
Helps members to better manage costs
Low dispensing fees, No administration or delivery fees,
Advice on generic substitution to ensure lower or no copayments
Access to more information about their treatment/condition
To order or re-order medicine, members can use any of the
following:
SMS re-order
service
Note: *Johannesburg, Cape Town, Pretoria, Durban, Port Elizabeth
Note: **For medicine ordered before 15:00
MedXpress as designated service provider for
Delta options
1 Effective from 1 January 2014 for all new members and 1 July 2014
for all existing Delta plan members
2 Chronic medication of Delta members registered for CIB will be
covered in full if:
Ordered through MedXpress
Chronic medicine is on the formulary
Chronic medicine is off the formulary, but under the CDA
In other cases, member will face a co-payment
Funding
On formulary
Off formulary
Ordered through MedXpress
Not ordered through
MedXpress
Full Cover
20% co-payment
+
Any additional dispensing fees
Co-payment above CDA
20% co-payment
+
Any additional dispensing fees
+
Co-payment above CDA
The KeyCare Series in summary
KeyCare Plus
KeyCare Core
KeyCare Hospital Network
KeyCare Hospital Network for
emergencies and trauma;
KeyCare Access Hospital
Network* for child birth and care
of newborns
KeyCare Hospital Network
KeyCare Hospital Network
Contracted state hospitals
KeyCare Hospital Network
Critical
hospital
care
Planned
hospital care
KeyCare
Access
Chronic Illness
Benefits
Day-to-day medical
care
Cover for antenatal services
and specialist consultations
Screening and
prevention
KeyFIT
*A network of 32 private hospitals
Discovery Health product range
 THE KEYCARE PLANS
Unlimited emergency hospitalisation - Any hospital,
transfer to network hospital once stable
Critical
hospital care
Planned
hospital care
Chronic Illness Benefits
Day-to-day medical care
Screening and prevention
Vitality & KeyFIT
Unlimited planned hospitalization at a Network hospital
only, otherwise there is no benefit
Covers 26 Chronic conditions subject to formulary and
approved network supplier or their dispensing doctor.
A 20% co-pay applies outside of the network.
Through Discovery Health provider network
• GP consultations and minor procedures
• Medication subj. to formulary
• Basic blood tests and x-rays
• Basic dentistry
• Basic optometry, frames and lenses
Members may elect a secondary GP per beneficiary. One
out of network visit pbpa
Specialist Benefit- R2 750 pp (2013:R2550)
Antenatal benefit- 4 consults; 2 scan, selected blood tests
Mobility device benefit – R4450 per family
Casualty Benefit
• The casualty fee for ALL Keycare casualty units is R225
• Formularies apply in casualty
Screening benefit
This list
applies to
KeyCare
Access, only
for childbirth
and care for
the newborn
Applies to the KeyCare Core and Plus plans;
Applies to KeyCare Access but only for life threatening emergencies and defined
trauma events
Discovery Health product range
Plan
option
Keycare
Plus
Keycare
Core
Keycare
Access
Income bracket
Main member
Spouse/
adult
dependant
Child
dependant
(R0 – R6 650)
R695
R695
R251
(R6 651 – R8 800)
R973
R973
R272
(R8 801+)
R1 448
R1 448
R388
(R0 – R6 650)
R556
R556
R143
(R6 651 – R8 800)
R693
R693
R171
(R8 801+)
R1 070
R1 070
R241
(R0 - R3900)
R490
R490
R212
Agenda
AF Health’s commitment to you
FAIS requirements
Discovery Health product range
Vitality
Vitality’s model of making members healthier
KNOW YOUR HEALTH
IMPROVE YOUR HEALTH
ENJOY THE REWARDS
Complete the Vitality assessments
Engage in activities and earn points
Achieve a Vitality Status and enjoy the
rewards
HealthyFood benefit structure revised to incentivise
screening
Members without a
DiscoveryCard
2014
Members with a
DiscoveryCard
Activate the benefit
on discovery.co.za
Determine your
Vitality Age*
10%
15%
cash back at both
partners
cash back at your
preferred partner,
10% at the other
10%
15%
cash back at both
partners
cash back at both
partners
Complete a
Vitality Health Check*
cash back at your
preferred partner, 10%
at the other
cash back at
both partners
*Principal , spouse and adult dependant (where applicable) need to complete a
VHR and Vitality Check
Gap Cover Insurance - Admed Gap
 Admed Add+ is a voluntary top-up benefit to cover shortfalls in
hospitals
Admed Add+
Shortfall Cover
The shortfall , or gap, is defined as the amount by which the actual cost
charged by the medical practitioner exceeds the medical scheme
payment subject to a maximum limit of five times the Admed tariff, less
the medical scheme payment
Additional Benefits
•Personal Accident Cover
•Road Cover
•A once off lump sum of R10 000 on diagnosis of Breast and Prostate
cancer
•A stated benefit of R20 000 with no sub limits for co-payments and
deductibles (in hospital treatment)
Gap Cover Insurance - Admed Gap
Admed Add+
Additional Benefits
•Shortfalls resulting from MRI/CT/PET Scans done on an outpatient
basis will be covered from 2014. Covered by the stated benefit amount
of R20,000
•Oncology benefit – 20% co-payment that members are subjected to
once they reach their oncology benefit limit, will be covered up to a max
of the benefit limit of R250,000 per beneficiary per annum
Rate from 1
January 2014
Active members: R101
Retirees: R154




Guardrisk contact details:
www.guardrisk.co.za
Tel: 0860 102 936
Email: admed@guardrisk.co.za
For assistance contact us
 Our dedicated Service Team: 011 269 2690
 Email: hcclientservices@aforbes.co.za
 SMS the word ‘medical aid’ to 31768 and one of our
consultants will call you back (SMS charged at standard
rates)
 Discovery Health 0860 99 88 77 (24hrs) or access the
website at www.discovery.co.za.
Thank You
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