The Wealth Room

Discovery Health Medical Aid summarized benefits for 2019

In 2019, DHMS will balance the increasing demand for supply of healthcare services against the need to maintain competitive contributions and enhance benefits for members. The scheme will also expand access to private healthcare and enhance the digital healthcare experience for members.

Key themes:

• Contribution sustainability
• Enhanced benefits
• Greater access to healthcare

2019 Contribution Increase:

• Medical inflation for 2018 is expected to be between 11.2% – 12.2%, with the variation due to plan-specific utilisation effects
• Risk management interventions by Discovery Health & ongoing positive impact of Vitality on members’ health is expected to reduce medical inflation by 2%
• The resulting medical inflation is therefore between 9.2% – 10.2%, which is 3% to 4% above CPI after allowing for the adjustment of VAT

The 2019 weighted average contribution increase for Discovery Health Medical Scheme (DHMS) is 9.2% (including 1% to account for the VAT increase), which is within the expected range for medical inflation, and maintains the competitive price advantage of the Scheme in 2019.

The contribution increases for 2019 are linked to medical inflation and the increase in VAT, but reflect the plan-specific elements of medical inflation:

• Tariff inflation is on average equivalent to CPI, and is consistent across all plans
• Utilisation inflation reflects plan-specific experience -Executive, Comprehensive and Coastal Plans have higher increases due to greater demand-side and supply side inflation

2019 Contribution increases per plan type:

• The cumulative annual contribution increases relative to CPI (2010-2018) for DHMS members has remained within 3% to 4% of Consumer Price Inflation over the period.
• The cumulative annual contribution increases for DHMS have remained approximately 1% below that of the rest of the open scheme industry
• Maintaining this differential over time means that members of the Scheme on average contribute 4% less in 2018 than members of other open medical schemes for equal or better benefits

DISCOVERY DAY SURGERY NETWORK

• Discovery Day Surgery network 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
• The DSP will apply for a defined list of day procedures
• Network facilities to be published on the web site in November
• Members will be liable for a R5,000 deductible for out of network procedures (Smart and Delta plans will encounter a deductible of R8,800 or R6,650 respectively)
• In an event of an emergency, the deductible is waived
• KeyCare members have no cover should they not utilise the DSP

INTRODUCTION OF DESIGNATED SERVICE PROVIDER FOR RENAL DIALYSIS AND ONCOLOGY

• Applicable on the Essential Smart plan
• Members to be covered in full for oncology and renal dialysis, through a network
• Renal dialysis will be covered in full through state facilities
• Oncology will be covered in full in the ICON network
• 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 – DESIGNATED PROVIDER FOR CHRONIC MEDICATION

• In 2019, MedXpress becomes the DSP for chronic medication on Priority and Saver plans
• Members not utilising MedXpress will encounter a 20% co-payment on medicine and dispensing fees
• 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
• MedXpress pharmacy network includes:
  • Clicks
  • Dis-Chem
  • 63% of retail pharmacies
• 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

• Co-payments and deductibles will increase – refer to the member guide attached for plan specifics
• ATB will increase as follows:
  • Executive: 9%
  • Comprehensive: 9%
  • Priority: 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

CHRONIC BENEFIT UPDATE 2019

• From 1^st Jan, the 2019 updated chronic formulary and CDA will be implemented
• Existing members have been receiving communication since August 2018 confirming the changes and impact
• These members have until the end of 2018 to make changes, to avoid or reduce co-payments

KEYCARE SERIES 2019

• The KeyCare Series has been restructured for 2019
• Changes have been made to maintain benefits for members with significant healthcare needs on KeyCare Plus and KeyCare Core, while retaining affordable access to private healthcare through KeyCare Start
• Funding of all endoscopes on KeyCare will be limited to PMB cover
• KeyCare Access has been renamed KeyCare Start with a redesigned benefit structure
• The 2018 income bands below R13,050 on KeyCare Plus and KeyCare Core have been consolidated into one income band
• Below are the 2019 revised income bands:

KeyCare Start:

• Premiums for the KeyCare Start plan begin from R839 per month
• The plan offers extensive day to day and hospital cover and preventative care benefits through an innovative combination of healthcare networks
• KeyCare Start members will access healthcare through innovative ‘hub and spoke’ regional networks, arranged around 17 unique regions
• Each regional network is designed around an anchor ‘hub’e. a KeyCare Start hospital offering an array of medical, surgical and emergency services
• The hubs are surrounded by the KeyCare Start GP Network as well as a network of facilities and healthcare professionals providing routine services

KeyCare Start Benefits:

• Unlimited cover for admissions in the member’s chosen KeyCare Start Network hospital
• Cover for emergencies outside the KeyCare Start Network hospital
• Unlimited cover for a list of procedures in the regional KeyCare Start Day Surgery Network
• Full cover for specialists and healthcare professionals contracted to KeyCare, and up to 100% of the Discovery Health Rate for non-contracted specialists and healthcare professionals
• Cover for after-hours emergency visits to the member’s KeyCare Start GP
• Unlimited GP visits at the member’s selected KeyCare Start GP
• 2 out-of-network visits to a KeyCare Start GP
• Acute medicine dispensed by the member’s KeyCare Start GP
• 2 specialist visits covered up to R2,000 per beneficiary, if referred by the member’s KeyCare Start GP
• Formulary driven radiology and pathology
• Defined conservative dentistry at Dental Risk Company (DRC)
• Defined optometry at IsoLeso
• Chronic medication, oncology treatment and renal dialysis through a state facility
• Annual health check at a wellness provider for adults and children
• Funding of all endoscopes on KeyCare Smart will be limited to PMB cover
• As no chronic benefit is available on this option, member will be allowed to upgrade upon diagnosis, within 30 days

Existing KeyCare members – Plan selection process for 2019:

KeyCare members will receive detailed, personalised communication during October.

1. Members on KeyCare Access in 2018 will be transferred to KeyCare Start in 2019 (based on their income band as at 31 December 2018). These members have the option to change their plans until 30^th June 2019
2. Members on the lowest income band of KeyCare Plus in 2018 will remain on the lowest income band of KeyCare Plus in 2019; these members will have the option to change their plan until 30^th June 2019
3. Members on the lowest income band of KeyCare Core in 2018 will remain on the lowest income band of KeyCare Core in 2019; these members will have the option to change their plan until 30 June 2019

PRIMARY CARE 2019

2019 brings with it significant enhancements to the Primary Care Trauma Benefit.

• The existing Trauma Hospital Network will fall away and members will have access to emergency treatment for the list traumatic events at any hospital or casualty facility
• The R100,000 (maximum) per event cover provides full cover for all hospital and related costs (previously covered at the Discovery Health Rate)

HEALTHY COMPANY 2019 (DISCOVERY EAP)

• Proactively supports at risk and healthy employees by managing four key dimensions of their well-being:
  • Physical
  • Emotional
  • Financial
  • Legal
• Through risk classification Healthy Company is able to provide proactive and tailored interventions with data driven insights
• Healthy Company pricing presents a 21% discount to traditional employee assistance and wellness programmes
• Pricing is based on the unique circumstances of each business, including size of the work force and current Employee benefits (discounts up to 72% may be applied based on current Discovery provided employee benefit products e.g. Health, Primary Care, Retirement Funds and Group Life)

ONCOLOGY CARE 2019

The current oncology benefit covers more than 98% of member’s treatment costs in full, with no member co-payment.

DHMS Oncology Trends:

• 38,000 members were funded for cancer treatment in 2017 – an increase of 45% since 2011
• R15billion paid in claims by the scheme between 2011-2017 with a +103% increase in annual claims costs between 2011 – 2017
• + 8,000 newly diagnosed members with cancer in 2017 with the most commonly diagnosed being breast, lung, prostate and colorectal cancers
• >200 treatments currently available for cancer
• + 14 new targeted medicines were registered in 2018 – 11 of which are designated as ‘breakthrough therapies’

In order to maintain this cover for members in 2019, the Oncology Care Programme must account for the increasing number of members being treated for cancer, as well as the rapidly, evolving developments in oncology treatment options:

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 from Rand 1
• 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

DHMS 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:

1.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
• Programme will include:
  • Annual cardiovascular assessment
  • Recommended clinical pathways
  • A personalised member scorecard to track clinical improvement measures over time

2.Mental Health Care:

• A Premier Plus GP can enroll members with major depression, based on defined clinical entry criteria
• The below benefits will be provided from risk:
  • 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

  • Two additional GP consultations

Diabetes Care: Nurse Educator Programme to be introduced in 2019

• A supplementary Nurse Educator programme is to be introduced, to support the Premier Plus GPs with the effective monitoring and management of members on the Diabetes Care programme
• The programme will include:
  • Medicine adherence
  • Effective eye and foot care
  • Promotion of healthy nutrition and physical activity  

DISCOVERY VITALITY 2019

• Proud introduction of new Vitality Ambassador – Caster Semenya
• In 2019, Vitality is introducing a series of enhancements to make healthy living even more accessible to members, and for the first time ever, Vitality is open to ALL South Africans (for 10 weeks)
• Key product updates:
  • New Vitality Active Rewards 2.0 gameboard: Allows members to earn more rewards, more often
  • Personalised health goals: Vitality Active rewards journey includes in-app tracking with personalised nutrition, preventative screening, weight management and medicine tracking
  • Vitality Open: for 10 weeks only, all South Africans can access Vitality Rewards
  • Healthy Dining: Get up to 25% cash back for choosing healthier meals when dining in or dining out, plus half price kids meals
  • Device booster enhancements: No device booster activation fee with new device options including low cost heart rate device
  • Special offer for new members: Join during Vitality Open and pay R799 gym joining fee or choose a R500 voucher to spend at Woolworths or Pick n Pay

Vitality points structure

• Gym visits with a minimum duration of 30 minutes will qualify for 100 points
• Members will earn up to 1,200 vitality points per month by tracking step activity – all step activity will count towards Vitality Active Rewards
• Members can now earn up to 25% cash back when participating in GoSmokeFree through Clicks or Dis-Chem
• Members will be able to earn points using Huawei fitness devices
• For a limited period in 2019, new Vitality joiners can save on the Huawei Band 2 Pro
• No activation fee will apply to Device Booster in 2019

2018 Vitality Active Reward Version 2.0

• Vitality Active rewards is being extended to increase and sustain engagement across the following health behaviours:
  • Health behaviours: preventative screening, weight loss management, nutrition and medicine adherence are now included
  • Personalisation: Members can access new goals based on their personal medical history and health check outcomes
  • Rewards mechanics: Members now have an opportunity to earn higher value rewards through the new gameboard
  • Incentives: Vitality Rewards can be converted to Vitality points towards their status, or spent on coffee, smoothies or shopping vouchers

Vitality Active Rewards Structure

This has morphed into a gaming board where members can choose a tile revealing a lucky reward

Rewards will take the following form:

• Vitality Reward points (which convert into monetary value and can be saved, converted to Vitality points or spent at Vitality Partner stores) of 25 or 40 or 100
• Diamond Rewards hold a higher monetary value than normal Vitality Reward Points
• Each time a Diamond reward is chosen over the next 10 weeks, members are entered into a draw to win further prizes for life i.e. Coffee for life, fuel rewards for life, tyres for life etc

Introducing Vitality Open

For the first time ever, Vitality is open to all South Africans for 10 weeks only.

• All South Africans aged 18 and older can download the app from the 13^th Sept to 23^rd Nov
• They need to get active, drive well, get rewarded and get an opportunity to win prizes for life

Reduced gym activation fee to continue

• The campaign around the once off activation fee of R799 (at a Virgin Active or Planet Fitness Gym) to new members has been extended until the end of December 2018 – This is a saving of R1,196
• Wearable devices: Members qualify for a 50% savings upfront and up to 50% cash back through Device Booster for a Huawei Band 2 Pro for meeting your Vitality Active Rewards fitness goals

New in 2019: HealthyDining

The HealthyFood benefit is being extended to members when they decide to eat out.

HealthyDining has been introduced where members can get up to 25% cashback on Healthy Dining meals through accredited providers namely:

• Woolworths Café
• Col’Cacchio
• Doppio Zero
• Nandos
• Ocean Basket
• Uber Eats app to be enhanced so members can experience the Healthy Dining concept
• Limited to R200 per meal and R1,000 per month (for a single member) and R400 per meal and R2,000 per month (per Family)

DISCOVERY COMPREHENSIVE GAP COVER – 2019

Discovery comprehensive Gap cover will now include:

• Scopes and Scans Benefit Extender:
  • Hospital account for Endoscopies (gastroscopy, sigmoidoscopy, proctoscopy and colonoscopy)
  • Out of hospital MRI and CT scan co-payments (when the medical scheme covers the rest of the account)
• Travel Benefit Extender:
  • Cover for shortfalls on medical treatment while travelling outside of South Africa, including the following:
    • Cover for the $150 or €100 deductible for out of hospital emergency claims when travelling
    • Shortfalls on emergency claims once you have reached your International Travel Benefit limit of R5 million or $1million on Executive plans, per person, per trip
    • Cleveland Clinic and MyConsult second opinion shortfalls will be covered