discovery health medical scheme changes for 2014 communication/ibm... · 2014-09-27 · discovery...
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October 2013
Dear IBM – Discovery Health member
DISCOVERY HEALTH MEDICAL SCHEME CHANGES FOR 2014
This letter provides you with details on various changes announced by Discovery Health for 2014. Discovery Health Medical Scheme will send you a brochure containing a detailed summary of the 2014 benefits and rate. This is your opportunity to change your plan option with effect from 1 January 2014. To make the right choice, you need to consider your healthcare needs and ensure you choose the right level of cover for 2014. You don’t have to make a change, but if you want to amend your current plan option, you need to submit your option change by logging onto www.afhealth.co.za\ibm, and selecting your change for 2014, before 29 November 2013. All 2014 Discovery Health information and a copy of the presentation can be found on the Intranet site on www.afhealth.co.za\ibm
CHANGING YOUR PLAN OPTION You have until 29 November 2013 to change your plan
OTHER CO-PAYMENTS AND LIMIT CHANGES Changes in co-payment amounts and limits
NEED ASSISTANCE? Who to call for information, advice and questions
DAY TO DAY BENEFITS Changes on the Insured Network Benefit and new preferred medicine list (acute medication)
CONTRIBUTION INCREASE Discovery Health announced a 8.9% average increase for 2014
KEYCARE BENEFIT CHANGES Changes to income bands and limits
HOSPITALISATION CHANGES Changes to networks and deductibles
VITALITY CHANGES Extended HealthyFood benefit, travel benefit and new hotel collection, Livewell and Smartphone and fitness devices
COMPASSIONATE CARE BENEFIT The Terminal care benefit amended and limits increased
GAP COVER Increase and benefit changes to AdmedAddPlus.
CHRONIC ILLNESS BENEFIT Formulary changes and new benefits
WINDOW PERIOD Employees who would like to join Discovery Health effective 1 January 2014, may do so, without any penalties
CHANGING YOUR PLAN OPTION
How much will your company pay towards your medical aid? Active Members Contributions are 100% member paid via the company payroll. When will member information sessions be held? Your Alexander Forbes Health consultant and a Discovery Health representative will provide training on the 2014 plan options. The dates and times of the member information sessions are included below:
Area Date Time of Presentations
Presenter One on One Member Consultations
Consultant assisting with One on Ones
Sandton 12 November 9am – 10am Rachel Janssens in the auditorium
10:30 – 16:00
Nkosinathi Siyoko from AF Health and Janandrin Moodley from Discovery Health
Sandton 12 November 1pm – 2pm
Sandton 13 November 11am – 12pm
Sandton 14 November No presentation
Cape Town 18 November 9am – 10am
Fauzia Mohidin – in the auditorium
10:30 – 16:00
Fauzia Mohidin from AF Health and Shereen Ashraff from Discovery Health from 10:30am
Cape Town 19 November
Durban 18 November 9am – 10am Ayanda Uche in Meeting Room 1
10:30 – 16:00 Ayanda Uche from AF Health and Louis Perumal from Discovery Health (Discovery assistance only on 18 November)
Durban 19 November
Port Elizabeth (Note: Cars to be parked outside the premises)
18 November 9am – 10am Noxolo Stemele
10:30 – 15:00 Noxolo Stemele
Should you wish to make an appointment to see a consultant after the presentation please book a time by
logging onto www.afhealth.co.za\ibm. Please remember to record the event in your calendar. How to change your plan
If you want to change your option for 2014, log onto www.afhealth.co.za\ibm and click on the option change icon. Once you have made a plan change, please ensure that you click on the confirm button to ensure the option change is recorded. If you do not make an option change prior to the deadline, you will remain on your current plan option until 2015.
ASSISTANCE WITH CHOOSING YOUR PLAN OPTION
Contact the Discovery Health Medical Scheme for general plan information by:
Browsing the Discovery Health website www.discovery.co.za; Browsing the AF Health / IBM intranet site www.afhealth.co.za\ibm; Making use of the national walk-in centres;
Discovery magazine (spring edition). Alexander Forbes Health consultants will be available to assist you to make the right plan option choice.
Health office Tel number Email address
Discovery Health 0860 100 694 healthinfo@discovery.co.za. Alexander Forbes - Sandton office 011 269 2690 hcclientservices@aforbes.co.za
Alexander Forbes - Stellenbosch office 021 809 3777 clientspecialist@aforbes.co.za
.
CONTRIBUTION INCREASE
The average contribution increase, effective 1 January 2014, of 8.9% reflects a view of the current industry scenario and the scheme’s sound operating position. The increase is applicable to all plan options. However as a result of the rounding of numbers a few variations do exist. Please refer to Annexure A for the 2014 contributions as well as the increased threshold levels on the Priority, Comprehensive and Executive Plans.
HOSPITALISATION CHANGES
Networks Refer to Annexure C for the list of hospitals applicable to the KeyCare series and Delta plan options. KeyCare Core and KeyCare Plus members must go to one of the listed KeyCare network hospitals for planned hospital admissions. If you do not use these hospitals for planned hospital admissions, you’ll need to pay the bill. The same hospital network list applies to KeyCare Access members in case of life threatening admissions and defined trauma events only. The KeyCare Access Hospital Network list applies to KeyCare Access members, but only for childbirth and care for newborns. Other approved hospital admissions for KeyCare Access members are covered in Discovery’s network of state facilities. The Delta Hospital Network applies to all Delta plans for planned admissions. The deductible is not applicable in case of life threatening admissions. Deductibles Priority plan members should note that the defined deductibles for in-hospital procedures will range from R2 150 to R10 500 in 2014. Please refer to Annexure B for more details. Delta plans members should note that the deductible has increased from R5 000 to R5 450, if you do not use the Delta Hospital Network for planned procedures. The 2014 deductibles for in-hospital or in day-clinic dentistry treatment are as follows:
Category of members In-hospital treatment Treatment in Day-clinic
Members younger than 13 years R1 550 R 750
Members older than 13 years R4 000 R2 600
COMPASSIONATE CARE BENEFIT
The Terminal Care Benefit will be renamed to the Compassionate Care Benefit. It provides access to extended home-based holistic care, including services such as pain relief, hydration, nursing and support care such as
hospice services. A benefit of R40 000 for each person in their lifetime will be applicable to all plan options, except for the KeyCare plans where a limit of R28 500 for each person in a lifetime will apply.
CHRONIC ILLNESS BENEFIT (CIB)
Discovery’s CIB medicine list and Chronic Drug Amounts (CDA) for 2014 have been reviewed based on annual pricing movements. From next year, members of the Delta plan options will have to use the scheme’s courier pharmacy (MedXpress) to obtain their chronic medication. If you don’t use MedXpress a 20% co-payment will apply.
Funding Ordered through MedXpress
Not ordered through MedXpress
On formulary Full Cover 20% co-payment + Any additional dispensing fees
Off formulary Co-payment above CDA 20% co-payment + Any additional dispensing fees + Co-payment above CDA
Above-mentioned changes will be implemented on 1 January 2014 for all new members and on 1 July 2014 for existing members. Managing diabetes digitally The iFORA Diamond Mini Telemetric Glucometer will be funded by the scheme from January 2014 via MedXpress or at Dischem pharmacies for all diabetic members registered on the Chronic Ilness Benefit (except KeyCare Plan members). This device captures blood glucose readings (replaces home diary), insulin medicine levels, and logs exercise and meals in real time. This data integrates seamlessly with HealthID and LivingVitality and can be accessed remotely by doctors. The iFora app can be downloaded free of charge for iOS and Android devices (in development for Blackberry devices). The offer is valid for one device per member for 2014.
OTHER CO-PAYMENTS AND LIMIT CHANGES
Co-payments and deductibles will increase in line with the overall increase (kindly refer to the Discovery Health brochure for various limits per plan)
The co-payment for MRI/CT scans will remain constant at R2 450 per scan, where applicable
Limits for surgical devices will increase by surgical inflation Limits for Oncology will remain constant:
Benefit option Oncology Limit
Executive and Comprehensive plans
R400 000 per member for approved cancer treatment in a 12-month cycle, a co-payment of 20% applies after the limit has been reached
Priority, Saver, Core plans R200 000 per member for approved cancer treatment in a 12-month cycle, a co-payment of 20% applies after the limit has been reached
KeyCare Cover according to the Prescribed Minimum Benefits and cancer specialists within Discovery’s network for KeyCare members
DAY TO DAY BENEFITS
Medical Savings Account (MSA), Insured Network Benefit (INB) and Above Threshold Benefit (ATB) Members registered on Core plans do not have access to day to day benefits. KeyCare Plus and KeyCare Access plan options, offer defined unlimited benefits through network providers. All other options provide day to
day cover through the Medical Savings Account, Insured Network Benefit and Above Threshold Benefit (where applicable). Medical Savings Account (MSA)
Day-to-day expenses are initially paid from the MSA
All unused funds are carried over to the following year
The funds in the MSA is available upfront to the member and dependants
The funds in the MSA will be prorated if the member joins mid year
The allocated amount will be based on the members’ plan and family size and the the percentage allocation is based on a stipulated percentage of the total contribution:
o Classic – 25% of contribution (except Classic Comprehensive Zero MSA, which has no MSA) o Essential – 15% of total contribution o Coastal – 25% of total contribution
Insured Network Benefit (INB)
Day-to-day expenses are paid from the INB once the annual MSA allocation has been depleted
The benefits can only be accessed through Discovery network providers
The 2014 INB will consists of: GP Consultations, Pathology (blood tests), Acute Medication and a new Maternity and External medical items benefit:
GP
Consultations Pathology Maternity Benefit Acute Medicine External Medical
items
Networks DH GP Network only
At Dischem, Clicks and MediRite pharmacies only
Gynaecologist and obstetrician within Discovery network of providers (All Classic and Premier Gynaecologists and Obstetricians)
At Dischem, Clicks and MediRite, MedXpress and a network of independent pharmacies
A network of independent providers
Description Consultations fees
Blood tests Antenatal consultations and 2D pregnancy scans; 2D scans will be covered in the INB if a member has already claimed for 2 scans while in their MSA
Preferentially priced, generic and brand medicines (Scheduled 3+); Acute medicine benefit has been re-designed to offer members preferential cover for medicines beyond a generic or brand innovator medicine status
A defined list of durable external medical items subject to external medical items sub-limit are included, for example
Mobility aids: wheelchairs and walkers
Breathing devices: CPAP machines, APAP machines, VPAP machines and portable oxygen concentrators
Insulin pumps
Consultations 2D pregnancy scans
Executive Unlimited Unlimited Unlimited 2 Unlimited Unlimited
Classic Comprehensive Unlimited
Classic Delta Comprehensive Unlimited
Classic Comprehensive Zero MSA
No Benefit No Benefit No Benefit No Benefit No Benefit No Benefit
Essential Comprehensive Unlimited Unlimited
Essential Delta Comprehensive
Classic Priority Unlimited Unlimited up to the ATB
2
Essential Priority No Benefit No Benefit No Benefit
Classic Saver Single: 3 Family:6
8 2 No Benefit
Classic Delta Saver
Essential Saver Single: 2 Family:4
No Benefit No Benefit
Essential Delta Saver
Coastal Saver Single: 3 Family:6
Above Threshold Benefit (ATB)
The Executive, Comprehensive and Priority plans include an ATB that provides further day to day cover once claims have accumulated up the to applicable annual threshold levels. The ATB is unlimited on the Executive and Comprehensive series whilst there is a limited ATB on the Priority plan. The Saver plans do not offer an ATB. Please refer to Annexure A for the applicable threshold levels. Preferred Medicine List for acute medication The 2013 medicine list has been amended to include both generic and non generic (brand items). The generic medicines which have been removed from the list (28 generic items) have a generic or brand equivalent on the new list, 22 brand names items have been added. Certain brand name items will be covered from 2014 such as:
Symbicord – no generic equivalent
Logynon – 35% more affordable than generic equivalent Discovery Health will pay up to 100% of the DHR for medicines included on their preferred medication list, from MSA. Those medicines not included on the preferred medication list, will be reimbursed at and accumulate at 75% of the Discovery Health rate.
2013 Day to Day 2014 Generic Medicine 100% accumulation Cover from INB and ATB Preferred Medicine list
Non-generic medicine 75% accumulation Cover from ATB only Medicine not on Preferred Medicine list
Discovery Health will pay and accumulate up to 90% of the DHR on the Executive Plan. Netcells Biosciences – Stem Cell Banking From 2014, all members will be entitled to an upfront discount of up to 25% on umbilical cord blood and tissue stem cell banking through Netcells Biosciences.
KEYCARE PLANS
KeyCare income bands have been increased by an average inflationary amount of 6.3%. Kindly refer to Annexure A for the new income bands;
The Specialist benefit amount will increase from R2 550 to R2 750 per person;
The Casualty benefit co-payment (facility fee) will increased from R205 to R225 per casualty visit;
The KeyCare plan option specific exclusions have been listed in Annexure B
VITALITY CHANGES
HealthyFood Benefit
In 2014 all Vitality members will have access to HealthyFood from Woolworths and Pick n Pay, irrespective of their plan choice
On activating the benefit Vitality members can get up to 10% cash back at Pick n Pay and Woolworths
Vitality members can get up to 15% cash back at Pick n Pay or Woolworths once they completed the online Vitality Health review to obtain their Vitality age
Vitality members can get up to 25% cash back at Pick n Pay or Woolworths once they completed the Vitality Health Check at a preferred provider
Members have to select a preferred partner, either Pick or Pay or Woolworths for the 25% cash back Members will also qualify for 10% when shopping at the other partner
DiscoveryCard holders (credit card) could qualify for up to 25% cash back at both partners
Members do not have to pay using their DiscoveryCard;
HealthyFood cash back also applies to Woolworths online purchases but not to Engen Woolworths store purchases
Identification mechanisms o Pick n Pay: HealthyFood card or your DiscoveryCard
o Woolworths: Woolworths Difference card or MySchool card (MySchool card members must first go to www.myschool.co.za and give permission to share their personal details)
Travel Benefit (Flights)
All international flights must be booked at least six weeks in advance and members may book a maximum of two international flights per person per year;
The following eight Quantas destinations have been added: Auckland, Perth, Sydney, Adelaide, Brisbane, Christchurch, Melbourne and Wellington;
101 additional new Emirates destinations have been added such as Athens, Milan, San Francisco, Rome, Toronto, Seattle and many more, whilst the Maldives and Phuket have been removed from the Emirates destinations for 2014
Maputo has been added by British Airways as a new destination
All flights go via Dubai when flying with Emirates, via Sydney or Perth with Quantas and via London with British Airways
All tickets must be booked through Kulula.com, through the kulula.com call centre or the Discovery member application
Booking fee of R29 per member per booking
Hotels
A new Vitality Hotel Collection (Tsogo Sun, Protea Hotels, Legacy Hotels, Thorny Bush Game Lodges and others), has been introduced which includes more than 500 top hotels, lodges, resorts and B&Bs
Discounts on Hotel Accommodation ranges from 15% to 35% and from 30% to 50% if booked using the DiscoveryCard
Accommodation must be booked through kulula.com
Booking no longer has to include a Saturday night
A booking fee of R25 for each room will apply to bookings made through Vitality;
Bookings must be for a minimum of two nights
Bookings must be made at least 21 days before the check-in date
Members can book for a maximum of 14 nights per year
Live Well Programme The Vitality Live Well programme runs in a 12 week cycle and will give members access to individually tailored advice, wellness specialists, support and tools.
Smartphone and Fitness Devices Fitness sessions can be logged on the Discovery App or a web-enabled device. Members will receive 50 bonus points for using one of the Fitness Devices.
COVER MEDICAL INURANCE
AdmedAdd+
Guardrisk Insurance Company will discontinue the AdmedGap product on 31 December 2013. On 1 July 2013, IBM elected to upgrade all Admed members to the AdmedAddPlus option at no additional cost to the members, so that members would have access to the stated benefit which would provide members with co-payment / deductible shortfall cover. Any members who elected to remain on the Admed option will be defaulted to the AdmedAdd+ product on 1 January 2014, unless the member opts for another product. Admed is a specially designed product which provides cover for the shortfall or gap, in the event of hospitalisation involving surgery or medical treatment and for certain procedures performed on an outpatient basis. The contribution for the mentioned policy arrangement will increase from R90 to R101 for active members and from R138 to R154 per family per month for the retirees with effect from 1 January 2014. The reason the increase is 12%, is due to the high claims ratio for both groups exceeding 100%.
The below table summarises the various products offered by Guardrisk. The changes from 2013 to 2014 have been highlighted.
Product Premium Description Additional Benefits
AdmedAdd +
Actives : R101
Retirees: R154
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 (2013: 4 times) the Admed tariff, less the medical scheme payment.
Personal Accident Cover, RoadCover 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)
The following changes will be implemented from January 2014:
The overall annual limit has been increased from R200 000 per beneficiary per annum (subject to an overall limit of R2 million per family per annum) to R250 00 per beneficiary per annum( subject to an overall limit of R2,5 million per family per annum)
The stated benefit has increased from R10,000 to R20,000
The once off lump sum benefit of R10 000 upon diagnosis of breast cancer has been extended to prostate cancer
The Personal Accident cover which was only available to the principal member has now been extended to all insured persons under Admed.
Shortfalls resulting from MRI/CT/PET Scans done on an outpatient basis will be covered from 2014. This amount will be 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.
Details of the benefits, general exclusions and waiting periods (only applicable to new entrants of voluntary membership groups) can be obtained from Alexander Forbes Health or the Admed website on www.admed.co.za. Existing employees/medical scheme members who have not yet joined Admed may join on 1 January. An application form needs to be completed and can be obtained from www.admed.co.za. The proposed demarcation rulings are still pending and may have an impact on these policies once finalised.
WHY THE OPEN WINDOW PERIOD? IBM Employees not currently registered on Discovery Health Should you belong to a different medical schemeand want to join Discovery Health you could do so, however, based on your health and previous medical aid cover, the scheme would be allowed to imposed waiting periods, exclusions and late joiner penalties onto your membership. With the Open Window period, you may join the scheme free of underwriting which means no restrictions will be imposed on your membership, provided you join the scheme effective 1 January 2014. Please bear in mind that special adult dependants (i.e. parents and siblings) will be subject to the normal underwriting process based on previous credible medical scheme coverage and any current Late Joiner Penalties, applicable to special dependants, will transfer across to the new scheme. To find out more about the benefits of joining Discovery Health please attend one of the presentation sessions being held at IBM Offices nationally, Alternatively, you can make use of one of the following resources for more information:
Browsing the Discovery Health website www.discovery.co.za; Browsing the AF Health / IBM intranet site www.afhealth.co.za\ibm; Making use of the national walk-in centres;
Call The Alexander Forbes service unit on 011 269 2690 or email the service unit on hcclientservices@aforbes.co.za
If you take the decision to join Discovery Health, please complete an application form, which can be found by clicking on www.afhealth.co.za\ibm and selecting Scheme Information followed by Medical Scheme Forms.
Please remember if you require chronic medication, you will need to apply for this benefit. The chronic application form can be downloaded by clicking on www.afhealth.co.za\ibm and selecting Scheme Information followed by Medical Scheme Forms.
IBM Employees currently registered as dependants on Discovery Health If you would like to transfer to the IBM Group Payroll, all you need to do is complete a continuation form, which can be downloaded by clicking on www.afhealth.co.za\ibm and selecting Scheme Information followed by Medical Scheme Forms. All application forms must be submitted to the Alexander Forbes Service Team by email to hcclientservices@aforbes.co.za or by fax to (011) 263-2397. Chronic application forms can be submitted directly to Discovery by fax to (011) 539-7000 or by email CIB_APP_FORMS@discovery.co.za, once you have received your membership number as this needs to be included on the form. Alexander Forbes Health is available to help you to make the right choice. Yours in health Alexander Forbes Health
To keep your finger on the pulse of the Medical Scheme industry, follow us on Twitter on @AF_Health.
Discovery Health Alexander Forbes Health – Stellenbosch
Alexander Forbes Health – Sandton
Admed/ Guardrisk
Tel: 0860 100 694 Email healthinfo@discovery.co.za
Tel: 021 809 3777 Email: clientspecialist@aforbes.co.za
Tel: 011 269 2690 Email: hcclientservices@aforbes.co.za
Tel: 0860 102 936 Email: Admed@guardrisk.co.za Website: www.admed.co.za
Alexander Forbes Health will endeavour to keep you informed as further information becomes available or changes. This
document serves as a simple summary of Discovery Health changes for 2014 and is not a comprehensive description of all changes, nor is it intended as advice. Alexander Forbes Health (Pty) Ltd will not be held liable for any errors herein. E & OE
apply.
ANNEXURE A 2014 TOTAL MONTHLY CONTRIBUTIONS
Series Plan Principal
Member
Adult
Dependant*
Child
Dependant*
Executive Executive R4 100 R4 100 R778
Comprehensive Classic Comprehensive R3 362 R3 180 R670
Classic Delta Comprehensive R3 028 R2 864 R602
Classic Comprehensive Zero MSA R2 522 R2 385 R503
Essential Comprehensive R2 825 R2 670 R568
Essential Delta Comprehensive R2 544 R2 403 R509
Priority Classic Priority R2 254 R1 774 R902
Essential Priority R1 937 R1 522 R774
Saver Classic Saver R1 976 R1 556 R790
Classic Delta Saver R1 578 R1 244 R633
Essential Saver R1 570 R1 175 R628
Essential Delta Saver R1 254 R942 R502
Coastal Saver R1 556 R1 166 R625
Core Classic Core R1 471 R1 157 R587
Classic Delta Core R1 177 R925 R471
Essential Core R1 263 R947 R506
Essential Delta Core R1 010 R757 R405
Coastal Core R1 087 R815 R434
KeyCare KeyCare Plus (R8 801+) R1 448 R1 448 R388
KeyCare Plus (R6 651 to R8 800) R973 R973 R272
KeyCare Plus (R0 to R6 650) R695 R695 R251
KeyCare Access (R8 801+) R1 416 R1 416 R381
KeyCare Access (R6 651 to R8 800) R942 R942 R267
KeyCare Access (R4 151 to R6 650) R653 R653 R235
KeyCare Access (R0 to R4 150) R490 R490 R212
KeyCare Core (R8 801+) R1 070 R1 070 R241
KeyCare Core (R6 651 to R8 800) R693 R693 R171
KeyCare Core (R0 to R6 650) R556 R556 R143
*Contributions are charged up to a maximum of 3 children; Dependants 21 years + are considered adult dependants.
2014 Medical Savings Account (included in the above monthly contribution, where applicable)
Series Plan Principal Member Adult Dependant Child Dependant
Annual Monthly Annual Monthly Annual Monthly
Executive Executive R12 300 R1 025 R12 300 R1 025 R2 328 R194
Comprehensive
Classic R10 080 R840 R9 540 R795 R2 004 R167
Classic Delta R9 084 R757 R8 592 R716 R1 800 R150
Essential R5 076 R423 R4 800 R400 R1 020 R85
Essential Delta R4 572 R381 R4 320 R360 R912 R76
Priority Classic R6 756 R563 R5 316 R443 R2 700 R225
Essential R3 480 R290 R2 736 R228 R1 392 R116
Saver
Classic R5 928 R494 R4 668 R389 R2 364 R197
Classic Delta R4 728 R394 R3 732 R311 R1 896 R158
Essential R2 820 R235 R2 112 R176 R1 128 R94
Essential Delta R2 256 R188 R1 692 R141 R900 R75
Coastal R4 668 R389 R3 492 R291 R1 872 R156
ANNEXURE A 2014 ANNUAL THRESHOLD LEVELS Executive and Comprehensive plans
Executive Plan Comprehensive Plans
Principal member R12 300 R11 350
Per adult R12 300 R11 350
Per child* R2 300 R2 150
* A maximum of three children are counted when calculating the Annual Threshold
Priority plans
Annual Threshold Above Threshold Limit
Principal member R9 990 R8 500
Per adult R7 510 R6 050
Per child* R3 270 R2 920
* A maximum of three children are counted when calculating the Annual Threshold and Above Threshold Limit
2014 VITALITY & KEYFIT CONTRIBUTIONS
Single Member Member with one
dependant
Member with two or
more dependants
Vitality R169 R199 R225
KeyFIT R36 R44 R55
Vitality & KeyFIT R179 R215 R249
LATE JOINER PENALTIES Please note these rates are the standard Discovery Health rates and do not take into account any late joiner penalties (LJP) that may be applied to an applicant or to the adult dependant of an applicant older than age 35. Depending on the number of years they have not belonged to a registered South African medical scheme, an additional penalty (a percentage of the contribution) may be added to the member's monthly contribution, as shown in the table below:
Penalty bands Maximum penalty
1 – 4 years 0,05 X contributions
5 – 14 years 0,25 X contributions
15 – 24 years 0,5 X contributions
25+ years 0,75 X contributions
The LJP is calculated as follows: A = B minus (35 + C) Where: A = the number of years in the first column B = the age of the applicant at the time of application C = the number of years of creditable cover
ANNEXURE B PRIORITY SERIES (DEDUCTIBLES) AND KEYCARE PLAN OPTION EXCLUSIONS Priority series deductibles
Members need to pay an amount upfront to the hospital when the member is admitted for one of the
following procedures:
DEDUCTIBLE AMOUNT PROCEDURE
R 2 150
Conservative back and neck treatment Myringotomy (grommets) Tonsillectomy Adenoidectomy
R 2 850
Colonoscopy Sigmoidoscopy Proctoscopy Gastroscopy Cystoscopy
R 5 150
Arthroscopy Functional Nasal Procedures Hysterectomy (except for pre-operatively diagnosed cancer) Laparoscopy Hysteroscopy Endometrial ablation
R10 500 Nissan fundoplication (reflux surgery) Spinal surgery (back and neck) Joint replacements
If the procedure can be done out of hospital, for example in the doctor’s rooms, and the member doesn’t go to hospital, the member won’t have to pay a deductible. It is recommended that members contact Discovery Health directly on 0860 100 694 prior to the procedure to confirm their benefits KeyCare Series exclusions In addition to the general exclusions that apply to all plan options, the KeyCare Series does not cover the following, unless it is a Prescribed Minimum Benefits: 1. Hospital admissions related to:
• Dentistry • Nail disorders • Skin disorders • Investigations and diagnostic work-up • Functional nasal surgery • Elective caesarean section, except if medically necessary • Surgery for oesophageal reflux and hiatus hernia • Back and neck treatment or surgery • Joint replacements, including but not limited to hips, knees, shoulders and elbows • Cochlear implants, auditory brain implants and internal nerve stimulators – this • includes procedures, devices and processors • Healthcare services that should be done out of hospital and for which an admission to
hospital is not necessary 2. Correction of Hallux Valgus/Bunion and Tailor’s Bunion/Bunionette 3. Arthroscopy 4. Removal of varicose veins 5. Refractive eye surgery 6. Non-cancerous breast conditions 7. Healthcare services outside South Africa Discovery Health does not cover the cost of treatment for any complications or the direct or indirect expenses related to any of these excluded conditions and treatments.
ANNEXURE C DISCOVERY HEALTH HOSPITAL NETWORKS AREA HOSPITALS DELTA KEYCARE
Core / Plus* Access**
EASTERN CAPE
East London Life Beacon Bay Hospital
East London Life St James Operating theatres
East London Life East London Private Hospital
East London Life St Dominic’s Private Hospital
Humansdorp Life Isivivana Private Hospital
Kokstad NetCare Kokstad Hospital
Port Elizabeth Life New Mercantile Hospital
Queenstown Life Queenstown Private
Uitenhage Netcare Cuyler clinic
Uitenhage Netcare Uitenhage Hospital
Umtata Life St Mary's Private Hospital
FREE STATE
Bethlehem Hoogland MediClinic
Bloemfontein Bloemfontein Eye Centre
Bloemfontein Netcare Pelonomi Private Hospital
Bloemfontein Life Rosepark Hospital
Bloemfontein Life Pasteur Hospital
Bloemfontein Netcare Universitas Private Hospital
Welkom Ernest Oppenheimer Hospital
Welkom Welkom Mediclinic
Welkom St Helena Hospital
GAUTENG
Alberton Clinton Hospital
Bedfordview Life Bedford Gardens Hospital
Benoni Life The Glynwood Hospital
Boksburg Botshelong Empilweni-clinic (Clinix Vosloorus)
Boksburg Sunshine Centre
Brakpan Life Dalview Clinic
Fourways Life Fourways Hospital
Germiston Life Roseacres Clinic
Heidelberg Life Suikerbosrand Clinic
Johannesburg Netcare Rand Clinic
Johannesburg Morningside Mediclinic
Johannesburg Johannesburg Eye Clinic
Johannesburg The Donald Gordon Medical Centre
Johannesburg Netcare Garden City Clinic
Johannesburg Life Brenthurst Clinic
Kempton park Arwyp Medical Centre
Krugersdorp Netcare Krugersdorp Hospital
Lakefield Netcare Optiklin Eye Hospital
Lenasia Lenmed Clinic
Midrand Life Carstenhof Clinic
Pretoria Netcare Bougainville Private Hospital
Pretoria Centurion Eye Hospital
Pretoria Netcare Femina Hospital
Pretoria Life Little Company of Mary
Pretoria Life Eugene Marais Hospital
Pretoria Netcare Jacaranda Hospital
Pretoria Legae MediClinic
Pretoria Louis Pasteur Hospital
Pretoria Medforum MediClinic
AREA HOSPITALS DELTA KEYCARE
Core / Plus Access
GAUTENG CONT.
Pretoria Muelmed Hospital
Pretoria Pretoria-Eye Institute
Pretoria Zuid-Afrikaans Hospital
Randfontein Life Robinson Private Hospital
Randfontein Sir Albert Medical Centre
Roodepoort Life Wilgeheuwel Hospital
Sasolburg Netcare Vaalpark Hospital
Soweto Clinix Private Hospital - Tshepo Themba
Soweto Clinix Private Hospital - Lesedi
Springs Life Springs Parkland Clinic
Springs Life St Mary’s Women’s Clinic
Springs Netcare N17 Hospital
Thembisa Zamokuhle Private Hospital
Vanderbijlpark Emfuleni MediClinic
Vanderbijlpark Ocumed
Vereeniging Clinix Private Hospital - Sebokeng
Vereeniging Midvaal Private Hospital
Westgate Medgate Day Clinic
KWAZULU-NATAL
Amanzimtoti Netcare Kingsway Hospital
Chatsworth Life Chatsmed Garden Hospital
Durban Life City Hospital
Durban Life Entabeni Hospital
Durban Ethekwini Hospital
Durban McCord Hospital
Empangeni Life Empangeni Garden Clinic
Isipingo Life Isipingo Clinic
Kokstad Kokstad Private Hospital
Ladysmith La Verna Hospital
Newcastle Newcastle Private Hospital
Phoenix Life Mount Edgecombe Hospital
Pietermaritzburg Midlands Medical Centre
Pietermaritzburg Netcare St Anne’s
Pinetown Life Crompton Hospital
Port Shepstone Hibiscus Hospital
Richards Bay Netcare The Bay Hospital
Sydenham Nu Shifa Hospital
Tongaat Victoria Private Hospital
Westville Life Westville Hospital
LESOTHO
Lesotho Willie’s Hospital
LIMPOPO
Bela Bela St Vincent's Hospital
Phalaborwa Clinix Phalaborwa Private Hospital
Polokwane Limpopo MediClinic
Thabazimbi Thabazimbi MediClinic
Tzaneen Tzaneen MediClinic
MPUMALANGA
Barberton Barberton MediClinic
Emalahleni/Witbank Life Cosmos Hospital
Emalahleni/Witbank Emalahleni Day Hospital
Ermelo Ermelo Private Hospital
Middelburg Life Middelburg Private Hospital
Nelspruit Nelspruit MediClinic
Trichardt Highveld MediClinic
AREA HOSPITALS DELTA KEYCARE
Core / Plus Access
NORTH WEST
Carletonville Leslie Williams Private Hospital
Carletonville Western Deep Clinic
Klerksdorp Life Anncron Clinic
Mafikeng Victoria Private Hospital
Orkney West Vaal Clinic
Potchefstroom Potchefstroom MediClinic
Rustenburg Life Peglerae Hospital
Rustenburg Netcare Ferncrest
NORTHERN CAPE
Kathu Kathu MediClinic
Kimberley Kimberley MediClinic
Upington Upington Private Hospital
Vryburg Vryburg Private Hospital
WESTERN CAPE
Bellville Bellville Medical Centre
Bellville Louis Leipoldt MediClinic
Cape Town Netcare Christiaan Barnard Memorial
Cape Town Netcare UCT Medical Centre
Cape Town Cape Town Mediclinic
Claremont Life Claremont Hospital
Claremont Life Kingsbury Hospital
Ceres Ceres Private Hospital
Gatesville Gatesville Medical Centre
George Geneva Clinic
George George MediClinic
Hermanus Hermanus MediClinic
Kuilsriver Netcare Kuilsriver Private Hospital
Milnerton Milnerton MediClinic
Mitchells Plain Mitchells Plain Medical Centre
Mossel Bay Bayview Hospital
Oudtshoorn Cango Day Clinic
Oudtshoorn Klein Karoo MediClinic
Paarl Paarl MediClinic
Parow Panorama Mediclinic
Somerset West Vergelegen Mediclinic
West Coast Life West Coast Private Hospital
Worcester Worcester MediClinic
* This list applies to the KeyCare Core and Plus plans; The list also applies to KeyCare Access but
only for life threatening emergencies and defined trauma event
** This list applies to the KeyCare Access, only for childbirth and care for the newborn
Please note that the list of hospitals is subject to change. You can go to www.discovery.co.za for the
latest list of hospitals. The list does not include the day clinics where members can get treatment without
paying an amount upfront.
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