More and more South Africans are experiencing financial problems leading them to try to cut costs and thus leading them to cancel their medical aid. As Daberistic we advise you that you do not have to stay without cover and there are other affordable solutions that will give you peace of mind. We share below about Health Insurance. What is Health insurance? Is a type of insurance coverage that pays for medical, surgical, and sometimes dental expenses incurred by the insured. Health insurance can reimburse the insured for expenses incurred from illness or injury, or pay the care provider directly. The benefit could either be a fixed sum of money per day or a maximum lump sum of money which is paid if a specified health event takes place (e.g. a specific health condition develops). Health insurance policies usually only pay out if certain specific health-related events happen and do not pay your medical expenses as a medical aid scheme would. Unique Principles 1. Limitations and prohibitions: A hospitalisation policy may not cover medical expenses. A health policy, other than a Gap cover policy, may not require the policyholder or insured person to be a member of a medical aid scheme. 2. Waiting period: A hospitalisation policy, gap cover policy and HIV/Aids, tuberculosis and malaria testing and treatment policy may provide for a – general waiting period of up to 3 months; and A condition-specific waiting period of up to 12 months. An insurer may not impose a condition-specific waiting period on a policyholder’s health insurance policy if that policyholder, for at least 90 days before entering into a health policy with the insurer, had a health policy with materially similar benefits and had completed the condition-specific waiting period in respect of that health policy. Where a waiting period of a policyholder under a previous health policy had not expired at the time that that policyholder enters into a new health policy with materially similar benefits, the insurer may only impose a waiting period equalling the unexpired part of the waiting period in respect of that previous policy. 3. Disclosure requirements: A hospitalisation policy, gap cover policy and HIV/Aids, tuberculosis and malaria testing and treatment policy may not create the impression that it is a substitute for medical aid scheme membership. A hospitalisation policy may not create the impression that it covers you for medical expenses. Three areas where Medical Aid Schemes and Health Insurance differ: If you would like to apply for health insurance, contact Jo in our Health department tel: (011)658-1333 email: service@daberistic.com
Source: CMS
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Discovery’s additional benefit the WELLTH fund came into effect on 01 January 2023. You and your family will have access to a once-off, additional risk benefit called the WELLTH Fund, offering up to R10 000 per family to empower you and your family members to understand and address your personal healthcare needs. What does the WELLTH Fund cover? The WELLTH Fund covers a comprehensive list of healthcare services to ensure that you are empowered to take specific action according to your individual health needs. This benefit is separate from and additional to the Screening and Prevention Benefit and will be available to all existing and new members of the Scheme. This benefit can be used for appropriate healthcare services up to your WELLTH Fund limit. Cover is subject to the Scheme's clinical entry criteria; treatment guidelines and protocols and qualifying healthcare services are covered up to a maximum of the Discovery Health Rate (DHR). Fund Allocation The WELLTH Fund is a once-per-lifetime benefit available to every beneficiary on Discovery Health Medical Scheme. The value of the benefit is allocated according to size and make-up of each family on a membership. To activate the WELLTH Fund, every person on a membership certificate aged 2+ must first complete their relevant health check at a healthcare provider in Discovery’s Wellness Network. Once the member and all their Dependants have completed their Health Checks, they will have access to WELLTH Fund of up to R10,000, below is a chart of how funds are allocated. The WELLTH FUND is allocated per membership, and therefore once it is activated any person on the membership can make use of any portion of the benefit. Discovery App WELLTH fund tracking On your Discovery APP the WELLTH Fund Dashboard (shown below) will allow members to view all available health checks and recommended next best actions, book consultations and keep track of their use of the WELLTH Fund. For more information on the Wellth Fund contact Jo in our Health Fund on 011 658 1333 or email us on service@daberistic.com
Source: Discovery Discovery’s additional benefit the WELLTH fund came into effect on 01 January 2023. This benefit is a once-off benefit to all medical aid members in which it provides up to R10,000 in additional cover for a family’s healthcare needs. Fund Allocation The WELLTH Fund will be activated in 2023, once members completed their health check in 2022 or 2023 This sets the baseline for a member’s Health Status. To activate the WELLTH Fund, every person on a membership certificate aged 2+ must first complete their relevant health check at a healthcare provider in Discovery’s Wellness Network. Once the member and all their dependents have completed their Health Checks, they will have access to WELLTH Fund of up to R10,000, below is a chart of how funds are allocated. Where to use your WELLTH Fund The WELLTH Fund covers over and above the annual Screening and Prevention Benefit. Discovery App WELLTH fund tracking On your Discovery APP the WELLTH Fund Dashboard (shown below) will allow members to view all available health checks and recommended next best actions, book consultations and keep track of their use of the WELLTH Fund. How tests are covered
This benefit is available once per beneficiary, per lifetime. Discovery pays the above healthcare services from the WELLTH Fund up to the Scheme Rate and up to your WELLTH Fund limit. Some of these tests and treatments have a rand value limit depending on the number of active dependents you have on your membership. Once you have reached your allocated rand value limit for the tests, Discovery will pay any extra screening and preventive tests and treatments from your available day-to-day benefits, where applicable. The Scheme’s clinical entry criteria, treatment guidelines and protocols apply. The normal claims process applies. Discovery will automatically pay this from your WELLTH Fund. FAQ
Yes, the WELLTH Fund covers the following specific medical devices if they have a registered NAPPI code and are bought from a registered healthcare provider with a valid practice number (such as a pharmacy or doctor):
It depends on which health plan you have. Plan network rules apply for members on Smart and KeyCare plans:
Members on all other plans may use a provider of their choice and do not have to use a network provider to be covered by the WELLTH Fund. 4. The WELLTH Fund tool has recommended a list of check-ups that I should go for, am I only covered for these check-ups? No, the WELLTH Fund Tool is just a guide for which screening check-ups are most suitable for you, based on your age and gender. However, you can go for any of the screening and preventative check-ups covered by the WELLTH Fund - you don't have to go for those recommended by the tool. 5. Can I claim for medication from the WELLTH Fund? No, you cannot claim any medication from the WELLTH Fund. 6. How can I book an appointment to use my WELLTH Fund?
For more information, please contact our Health department on 011 658 1333 or email us on service@daberistic.com Source: Discovery On 22nd February 2023, Discovery Health Medical Scheme (DHMS) announced the annual increase in member contributions for 2023. The Scheme used its strong reserve position to maximise affordability for members by delaying the annual contribution increases for a third year in a row, with the increases for 2023 effective from 1 April 2023. This allowed members to enjoy the enhanced 2023 benefits while paying 2022 rates for the first three months of the year. Enhanced Benefits for 2023 Wellth Fund:
Increase in Oncology Benefit
Disease Prevention
Premium Increase The contribution increases for 2023 are linked to medical inflation for Discovery Health Medical Scheme, with an adjustment for plan specific utilisation experience on extensive day-to-day plans. More and more people focus on health nowadays, it has increased by 40%. Survey shows that more people now think “Health” is more important, compared to pre-covid. For 85% of Scheme members, contributions will increase on 1 April 2023 by 7.9%, including members on the Keycare, Smart, Core and Saver Plans, and by 9.9% for members on the Priority, Comprehensive and Executive plans. The weighted average contribution increase for 2023 for the Scheme will be 8.2%, making the average annual increase 6.2%, limiting increases to CPI+1.9%. The key factors driving medical inflation for 2023 include:
New premium from 1st April 2023 Nowadays most medical schemes have a new-generation option that will typically be a hospital plan with a savings portion. This means the consumer has the peace of mind that he can go to a private hospital for procedures and has a small savings account for day-to-day expenses. What is a medical savings account? The medical savings plan is designed to cover day-to-day expenses while having fewer restrictions on the choice of providers. The consumer gets a total annual amount that is available in advance in his Medical Aid Savings to account for medical expenses. If a consumer joins the medical scheme during the year, this amount will be calculated pro rata. In terms of legislation, this amount may not exceed 25% of his annual premium. Once the savings are exhausted, the consumer will be responsible for any further day-to-day expenses. Any positive balance in the savings account at the end of the year will be carried over to the next year. If the member exhausts his savings component before the end of the year and switches to a new scheme or resigns from the scheme, the scheme may expect the member to repay the difference in savings to the scheme. The amount repayable by the member is the monthly savings multiplied by the number of months left in the year. Here are seven tips to make your medical savings last longer: 1. KNOW YOUR PLAN Understand what you’re covered for, at what rates and with which providers. Does your plan cover you at the medical scheme rate or at a higher rate? Does your plan require you to make use of a hospital or pharmacy network? Refer to the material you receive from your medical scheme, use their website and talk to your financial adviser about what your options are. 2. KNOW YOUR DOCTOR’S RATES Patients are often embarrassed to discuss money with their healthcare provider, but when you make the appointment, ask what rates your doctor charges and whether you’ll be liable for any co-payments. That way, you can make informed decisions about how you’re spending your healthcare funds. If affordability is your greatest concern, it might be better to shop around for a provider who charges scheme rates, but if choice is more important to you and you’re happy to pay more, you’ll know upfront exactly how much. 3. TAP INTO NETWORKS YOUR SCHEME MAY HAVE Some medical schemes have network arrangements in place with healthcare professionals. By using a network, the scheme pays the professional directly, reducing administrative hassle and keeping costs down for you. The Discovery Health Medical Scheme, for example, has an extensive GP network where members are covered in full for doctors’ consultations. We recommend that our members call us or visit our website before they see a healthcare professional, so they know which of these are part of a network. 4. IF YOUR SCHEME OFFERS DIRECT PAYMENTS WITH CERTAIN SPECIALISTS, YOU CAN BENEFIT TOO For example, Discovery Health Medical Scheme has direct payment arrangements in place with most of South Africa’s specialists on most of its plans. If you see one of them, you won’t be liable for any co-payments. If you choose to see another specialist, you may need to pay upfront or pay a portion of the costs yourself – depending on your plan. Find out what your options are. Don’t be afraid to discuss and agreed rates with your specialist. 5. CHECK FOR FULL-COVER ALTERNATIVES In the case of medicine for a chronic illness, schemes often have formularies – lists of medicine that are covered in full by the scheme. Check with your doctor or pharmacist if your prescribed medicine is covered in full and ask about options if not. 6. PAY IN CASH FOR OVER-THE-COUNTER MEDICINES If you have a medical savings account, don’t claim for items not normally covered by medical schemes, for example, over-the-counter headache tablets, cough preparations, etc, from your savings. Paying cash will help the money in your savings account last longer, so you have funds available for more serious, more expensive out-of-hospital treatments. 7. STAY HEALTHY! It seems obvious, but people often overlook the fact that by taking care of their health, they can reduce their healthcare costs in the long term. Make use of your scheme’s preventive screening benefits for regular health checks and live a healthy life. In the case of Discovery Health Medical Scheme, members have access to a range of preventive screenings funded by the scheme. Members can join Vitality, which rewards them for being healthy. Please contact our Health Department, email health@daberistic.com , to find out about different Medical aid options On 21st September 2022, Discovery hosted their virtual workshop with over 10,000 brokers, to announce Discovery's benefits and contribution updates for 2023. Below is a summary what you need to look forward to in 2023 for Discovery Health and Vitality. Discovery Health No increase in contributions until 01 April 2023 Every year, medical schemes increase contributions by medical inflation to meet the expected cost of healthcare claims in the following year. Discovery Health will only increase contributions for 2023 on 1 April 2023. Members will therefore enjoy 2023 benefits at 2022 rates, for the first three months of the year. The increase on 1 April 2023 will be in line with medical inflation, expected to range between CPI plus 3 - 4%, which would be about 10% increase. Discovery will only confirm the exact increase percentage and new premium in February 2023. 2023 Benefit updates
Introducing Essential Dynamic Smart Plan If you are a tech-savvy, then there’s good news! Discovery Health is introducing a new plan called Essential Dynamic Smart Plan in 2023, it only costs R1450 per month and it is personalized. It will connect a member with the most efficient hospital for their admission at a specific point in time. (Deductible/co-payment will occur if choosing other providers) Introducing the WELLTH Fund The WELLTH Fund enables members to better understand their health status. The fund does this by giving risk funding of up to R10,000 per family for a broad range of health screenings and preventive healthcare services – over and above the yearly Screening and Prevention Benefit. It is going to start from 01st January 2023 for 24 months. Simply unlock the benefit by having one health check-up. Vitality Highlights In 2023, Vitality will enhance its benefits to focus on monetizing healthy behaviour and encouraging good clinical outcomes to drive more engagement and better health. The Vitality HealthyWeight programme This new programme uses the latest trends in behaviour change to help members achieve their ideal and healthy weight through a personal nutrition coach, simple meal plans, recipes and shopping lists. Vitality members can access Vitality HealthyWeight at affordable rates, with all at risk Vitality members receiving higher additional discounts. The Easiest Way to Join Gym
If you have Discovery Bank, you can now join the gym with Vitality without any admin with the gym staff, you can simply activate the gym benefit on the App, and skip the gym activation fee! If you like to know more about your cover or review your current Option contact Tammy in our Health department tel (011) 658-1333 email: service@daberistic.com Source: Discovery All Medical aid Options would include: Accidental or emergency medical hospitalisation, maternity benefits, chronic illness benefits, oncology benefits, mammogram screening (once every 2 years), pap smear screening (once every 3 years), and prostate cancer screening (once a year). Below we detail each cover and how it works. Hospitalisation Whether your medical aid option is a hospital plan or a savers plan, as long as you are hospitalized in South Africa and obtain the hospitalization pre-authorization, you are covered. In case of emergency hospitalization, the hospital will contact the Medical aid company directly and obtain authorization When hospitalized, the hospital bill and the doctors’ bills are separate. In the case of elective hospitalization (planned procedure), the Medical Aid company will pay the hospital bill in full (in most of the cases). In terms of doctor's fees, medical aid company will pay according to the scheme rate. For example, if the scheme rate for a certain operation is R5,000, but the doctor can decide how much to charge. If the doctor charges R15,000, the Medical Aid company will only pay R5,000, and the remaining R10,000 is your liability. If you have Gap Cover, the the co-payment can be claimed back. If the patient is hospitalized due to an accident, an emergency or critical illness (such as cerebral hemorrhage), the doctor does not charge more than scheme rate, and the Medical Aid company will pay for the medical cost, and this is unlimited. In addition to applying for pre-authorization for hospitalization, you can also apply for pre-authorization with the Medical Aid company if you need to do endoscopy (as out-of-hospital) so that the Medical Aid company will settle the medical expenses. It should be noted that if your endoscopy is done in a hospital or a day hospital, you will need to pay a co-payment; If it is done in the doctor's room, there won’t be a co-payment. What should you do if the doctor asks you to request for pre-authorization? You need to ask the doctor for the following information and provide it to the Medical Aid company: • Medical aid membership number • Name the patient • Reasons for hospitalization or surgical items • Date and time of admission • Name and practice number of doctor • Hospital name and practice number • ICD10 codes and procedure codes Maternity Benefit If you have confirmed your pregnancy with your doctor, you can activate the maternity benefits with the Medical Aid company. After that, your medical aid would compensate 8 maternity check-ups up to scheme rate (about R480). Each obstetrician and gynecologists' charges different fees, you will then need to pay the amount exceeding the scheme rate. If your Gap Cover is with Sirago Ultimate option, 4 out of the 8 times, you may claim back the difference paid. Chronic Benefit If you are diagnosed with chronic illness, you can ask your medical aid broker for a chronic illness benefit application form, and ask your doctor to fill it out and send it to the Medical Aid company (or send it to the broker, who will send it to the Medical Aid company). In this way, you can go to the pharmacy for medicine every month, and the Medical Aid company will pay for the medicine. Cancer If you are diagnosed with cancer, you need your oncologist to provide a treatment plan and histology report to the Medical Aid company. Once the oncology benefit is activated, the first R200k of each cycle (12 months) will be paid in full, up to scheme rate. After that, Medical Aid company will pay 80%, and the remaining 20% will be your own expense. (if you have Gap Cover, the 20% co-payment amount can be claimed back) If your Gap Cover is Sirago's Ultimate option, the Gap cover will also compensate you R25k. Day-to-day Medical Expenses - Medical Savings If you are on a Savers option (or higher), you can enjoy day-to-day benefits. Every January, Discovery gives you your full-year savings which you may use throughout the year, if the savings are not used up by the end of the year, it gets rolled over to the next year and you can accumulate it and earn interest. If you are on a Priority, Comprehensive, or Executive plan, you also enjoy the Above Threshold Benefits, given that you have paid up the Self Payment Gap. What can you use Medical Savings for? You can use your Medical Savings for any out-of-hospital medical-related expenses, including but not limited to doctors' consultations, over-the-counter medication, dentists, glasses, certain co-payments (scopes, out-of-hospital CT/MRI scans), etc. Once the savings are used up, you will then need to pay for the medical expenses from your own pocket, until January the following year. Written by: Tammy Hua If you would like to review your Medical Aid option contact Tammy email: service@daberistic.com (tel)11)658-1333 Ext 106 |
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January 2025
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