This edition of Health-e is focused on updating our clients on Discovery Health’s benefit and contribution changes for next year. It is important that you make informed decisions regarding your medical aid plan option for 2019, and we have therefore included as much information as possible to help you with your decisions. Discovery Health has announced a weighted average contribution increase of 9.2% for next year, including 1% for the VAT increase, which is within the expected range for medical inflation and which maintains the competitive price advantage of the scheme for next year.
- DISCOVERY DAY SURGERY NETWORK
Discovery Day Surgery has been introduced for a range of medical procedures that can be performed on a same day basis. This network will become the Designated Service Provider (DSP) for Priority, Saver, Core, Smart and KeyCare plans in 2019, with all network facilities to be published online in November 2019. Members will be liable for a R5 000 deductible for out-of-network procedures, while the Smart and Delta plans will encounter deductibles of R8 800 and R6 650 respectively. Naturally, in the event of emergency the deductible will be waived. Importantly, Key Care members will not have cover if they do not use a Designated Service Provider.
- DESIGNATED SERVICE PROVIDER FOR RENAL DIALYSIS AND ONCOLOGY
A Designated Service Provider network is being introduced on the Essential Smart plan which will allow members to be covered in full for Oncology and renal dialysis if they use the network. Renal dialysis will be covered in full through state facilities and Oncology will be covered in full in the ICON network. Please note that Essential Smart members with an approved Oncology treatment plan may continue into 2019 at their current provider. Members going outside of the network will be covered up to 80% of the Discovery Health Rate.
- MEDXPRESS AS THE DESIGNATED PROVIDER FOR CHRONIC MEDICATION
In 2019, MedXpress becomes the Designated Service Provider for chronic medication on the Priority and Saver plans. Members not utilising MedXpress will encounter a 20% co-payment on medicine and dispensing fees. Please note that this change will be implemented from April 2019 for members already registered on CIB. For new members, the benefit must be utilised from 1 January 2019. The MedXpress pharmacy network includes Clicks, Dis-Chem as well as 63% of retail pharmacies in South Africa. Members without easy access to MedXpress pharmacies can have their medication delivered to their home or work, for free.
- UPDATES TO LIMITS, CO-PAYMENTS AND THRESHOLDS
Please note that co-payments and deductibles will increase from 2019, and the details can be found in the Member Guide 2019 attached hereto. The Above Threshold Benefit will increase as follows in 2019:
- Executive Plan: 11.9%
- Comprehensive Plan: 11.9%
- Priority Plan: 10.9%
Benefit limits are increased by the plan-specific contribution increases, with the exception of the internal prosthesis limit (which increases by surgical inflation). The below benefits are maintained in 2019:
- Overseas treatment limit
- Oncology Thresholds (98% of members treatment costs are covered in full, with no member co-payment
- Specialised Medication and Technology benefit
- Hip, knee and spinal prosthesis full cover when using the preferred provider
- External medical and appliance limit
New for 2019 for Executive and Comprehensive members:
- The Oncology Innovation Benefit: Provides members with cover for a list of innovative cancer treatments, subject to a 25% co-payment.
- The Extended Oncology Benefit: Provides members with full cover for a defined list of oncology treatments that are not considered PMBs and will not be subject to any co-payments once the R400 000 threshold is reached.
- 2019 CARE PROGRAMMES
Discovery Health offers members a number of condition-specific care programmes, managed through the Discovery Premier Plus GP network. Two new care programmes are being introduced in 2019:
- CARDIO CARE
Members diagnosed with hypertension, hyperlipidaemia and ischaemic heart disease can register on Cardio Care through their Premier Plus GP. Members have access to a risk funded extended consultation with their Premier Plus GP. In addition, the programme will include an annual cardiovascular assessment, recommended clinical pathways and a personalised member scorecard to track clinical improvement measures over time.
- MENTAL HEALTH CARE
A Premier Plus GP can enroll members with major depression, based on defined clinical entry criteria. This benefit includes an extended consultation with a Premier Plus GP, prescribed formulary medicine for episodes of major depression, including plans where major depression is not covered as a chronic condition, and two additional GP consultations.
Corlene & Chantelle