Discovery continues to lead the industry by rolling out exciting benefits and offerings: Mental wellbeing Shari'ah compliance arrangement Infertility and assisted reproductive therapy benefit Hospital network and day surgery updates New clinic and other services for employers Diabetes care programme Chronic Illness Benefits Co-payments and deductibles To find out more, please click on each tab below.
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Mental wellbeing Statistics according to WHO shows one in four people in the world will be affected by mental disorders at some point in their lives, this positions mental disorder amongst one of the leading causes of ill-health worldwide. Mental ill-ness often left undiagnosed and with 84% of adults never receiving treatment and this impacts society and WHO estimates cost to global economy may exceed $16 trillion by 2030. Discovery’s approach to alleviate this disorder, they have introduced management in mental wellbeing. Below programs offered are:
Shari’ah compliant arrangement From 2021 members from our Muslim community can appoint to have their contribution and claims across all plans to conform with Shari’ah principles through the Shari’ah compliant arrangement. • Model is compliant and is based on Takaful principles • Process flow happens in an acceptable manner • No interest earned or paid at any stage • No ambiguity in contracts • Members’ interests are protected • Investments are managed in Shari’ah Compliant manner • No interest earned or paid on Shari’ah Compliant arrangement. Funds will be invested in a compliant manner allowing members opportunity to earn profit on Medical Savings Account balances. • Members that partake in this arrangement attain affirmation on their contribution and balances remaining after settlement of claims and other expenditure will be invested in Shari’ah compliant investments. Infertility and assisted reproductive Therapy benefit When a couple is looking forward to building a family and the incapability to fall pregnant is aggravating. It affects many families and takes a emotional toll, however, many infertility cases can be remedied through treatment such as drug, surgical repair and assisted reproductive techniques including intra-urine insemination (IUI) and in vitro fertilisation (IVF). Taking a leap of faith on possibility to become a parent can come with a price tag, an average of R65000.00 – R85000.00 for a single IVF treatment cycle, this may be a hefty cost for many families in which will hinder and or have reservations from taking on this treatment. Discovery would like to support couples/ families distressed from infertility with introducing cover for Assisted Reproductive Technologies (ART) and the benefit will include cover for: • Up to two cycles of ART if Scheme’s benefit and clinical entry criteria are met. • This includes a series of care for the progress of the full duration: consultations, ultrasounds, oocyte retrieval, embryo transfers, admission costs including lab fees, medication and embryo and sperm storage. • The total limit of R110 000.00 per person per year at Discovery health rate applies. • Members will be subject to 25% of the costs and any excess above the Discovery Health Rate. • This benefit will be attainable at Southern African Society of Reproductive Medicine and Gynaecological Endoscopy (SASREG) accredited centres only and subject to clinical pathways and protocols. • Lastly, the benefit is only available to female members that has been on Executive and Comprehensive Plans for at least 2 years and the age between 25-42 years old.
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Chronic Illness Benefits
Diabetes Care Programme 2021 Premier Plus GP network will become the Designated service provider for members with Diabetes on the comprehensive plans. It is supported by the extensive coverage offered by the Premier Plus GP network and the clinical outcomes achieved by the diabetes care programme. The chosen GP will be member’s DSP for the ongoing management of diabetes as well as cardiovascular conditions. Statistics has shown in improvement when member’s care is coordinated by a single doctor. Hospital Network Updates and Day Surgery New hospitals will be added, and some existing hospitals will be replaced with region specific substitutions for 2021 to ensure continued optimisation of the Delta, Smart and KeyCare hospital networks In the Day Surgery, they will extend this offer to Comprehensive plans given focus on provider and patient safety because of COVID-19. The 2021 new hospital network and day surgery lists will be published by the end of October 2020.
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Limits, Co-payments, deductible and Thresholds
Next: Vitality 2021 - To Help members stay motivated Co-payments For Endoscopic Procedures
New Clinic and Other Services for Employers Daily monitoring of COVID-19 exposure, prevalence, and disease progression:
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1.Claiming from Medical Aid Daily Claims The day to day claims, like your Gp, Specialist, buying medication will be covered from your MSA Benefit, however if you are using a hospital plan, day to day is not submitted. Hospital claims. This is any claim that has been authorized for hospital stay, this can be a day or more than, so this will be paid from the hospital benefit Documents required to submit claim Valid invoice, not older than 3 months which must include, - Dr Details, Practice number, service date, ICD10 Code and Procedure code - Details of the patient i.e Name, surname and date of birth, Medical aid number Where to submit Medical Aid claim
2.Claiming From Sirago Any claims that needs to be submitted to Sirago has to submitted to your medical aid before claiming from the Gap Cover. Gap cover will only pay if it’s a valid claim which is based on one of the following:
Documents required to submit claim -Complete claim form -Invoices -Hospital statement -Medical aid statement, reflecting all the invoice or providers that has shortfall Where to submit
What happens when my benefits start and what do I need to know?
The following benefits needs pre-authorisation
The following benefits do not need pre-authorisation
How to get pre-authorization • Please call 0860102 493 to get an authorisation number • Please ensure that you have the information regarding the treatment required- E.g. Policy Number/ date of treatment/ Dr or Hospital practice number/ ICD10 Code, and Procedure Code Day-to- Day Benefits These are the benefits that are only available from your chosen Ingwe Active Primary Care network doctor. Chronic benefits to a list of medicine, referred to as s Network-entry-level formulary Day-to-day benefits are subjected to the network’s protocols, which are the rules and provisions set by the Network. Benefits are also subjected to the Network’s list of applicable tariff codes. What to do when wanting to see a doctor? You may visit any Doctor on the Ingwe Active primary care network. To check which doctors are in the area, you can call 0860 102 493 or visit Momentum website at Ingwehealth.co.za Momentum allows members to use any doctor on the Ingwe Active Primary Care network doctor. If you visit a non-Network doctor, you will have to use the emergency / casualty visit and pay R100 co-pay, this visit is covered at 100% of the Momentum health rate. There is no limit to the number of times that may visits the Ingwe Active Primary Care network doctor, however all the visits for the 11th onwards must be pre-authorised by contacting the call centre on 086 0102 493 How and where to find Doctor near your area To check which doctors, you can call 0860 102 493 or visit the website ingwehealth.co.za To apply for the Ingwe option for your chid please contact Nmahla or Tammy in our Health Department, email health@daberistic.com , Many people choose a health insurance option with a designated hospital or contract doctor. How to find doctors and hospitals has always been a problem for many people. Here are the steps to find a doctor or hospital close to your home or work location according to your health insurance options. Step 2: Click on “Find a doctor close to you”. Step 3: If you are looking for a hospital, click on “Hospitals and clinics”. If you are looking for a doctor, click on “Doctors”. Step 4: In the area bar, type the area you want to search for and select the option that appears automatically, or you can use the “current location”. Step 5: Click “Cover” and confirm that “Full network cover” is checked. Click apply. The names of different doctors (or hospitals) will appear below. Step 6: After you click on it, there will be contact information for the doctor (or hospital). If you have any questions, please contact Namhla or Tammy in our health department on (011)658 1333 or email health@daberistic.com
Medical schemes have various benefit plans available to members. Members have to choose between hospital plans, hospital plans with a savings component (New Generation Options), traditional plans, comprehensive plans and network plans. If your savings benefit is quickly depleted at the beginning of the year and you have to pay for expenses out of your own pocket, or if your option is too expensive, it would be worthwhile to reconsider your particular medical plan. Certain schemes allow migration to other options mid-year, while others allow such changes only at the end of the year. Traditional Plans Cover almost all medical expenses and include benefits for in-hospital, day-to-day expenses and chronic medication, subject to the rules of the scheme. These plans are recommended for individuals or a family who wants comprehensive cover, but does not want a savings benefit on there option. These options still cover emergencies, hospitalisation, day-to-day expenses and chronic medication. Comprehensive Plans These options have a savings component and cover almost all medical expenses and include benefits for in-hospital, day-to-day expenses and chronic medication, subject to the rules of the scheme. These plans are recommended for individuals or a family who want comprehensive cover for emergencies, hospitalisation and day-to-day expenses and that makes use of quote a lot of chronic medication. Basic Hospital Plans Cover accounts submitted by service providers only for in-hospital expenses. You are responsible for your own day-to-day medical expenses, including emergency ward treatment. Hospital plans cost considerably less than comprehensive medical plans. However, Heydenrych recommends that you first determine the difference between the premium of a hospital plan and that of a comprehensive plan before making your choice. Please contact Namhla or Tammy in our Health Department, email health@daberistic.com , to find out about different Medical aid options Source: medicalaid.co.za South Africa's Top 20 hospitals based on Discovery patient experience
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AuthorKevin Yeh Archives
January 2025
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