2014 - IBM Induction Presentation
advertisement
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
