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In part four of this series we looked at what exactly it is that the Discovery Health 2017 Comprehensive range offers in terms of benefits.

What gets confusing is the five slices that make up the Comprehensive cake:

1. Classic Comprehensive
2. Classic Delta Comprehensive
3. Classic Comprehensive Zero MSA
4. Essential Comprehensive, and
5. Essential Delta Comprehensive

Think of the Classic Comprehensive as the biggest slice and the Essential Delta Comprehensive as the smallest slice. Or here’s another way – how about slices one, two, and four as the fattest slices. Lucky for us we get the chance to grab a different slice every year.

So go ahead…now’s your first chance to decide whether you want the biggest slice.

The difference between the Classic Comprehensive Plans

I’ve mentioned this before about the Classic plans all paying 200% of the Discovery Health Rate (DHR) when it comes to in hospital treatment by medical professionals.

So the surgeon who operates, the anaesthetist who puts you to sleep (and who gives you a heck of a fright when you get the bill!), all get paid at 200% of the DHR. Which is good because they often charge way more than 100% of the DHR.

The hospital bill itself gets paid at 100% of the DHR and hospital coverage on all Discovery Health plans is unlimited.

What does unlimited mean?
Unlimited means you can book into hospital and Discovery Health will pay whatever the cost. A limited plan might offer you, for instance R500, 000 a year cover, and once your hospital bills reach that, they stop paying.

The Classic Comprehensive Plan

This plan is the most expensive of all the Comprehensive options since it offers the largest Medical Savings Account (MSA) of the range.

Let’s start off with the cost:

• Main member – R4, 506 monthly
• Adult dependants – R4. 264
• Children – R898 (A maximum of three children are charged for)

This gives us the following MSA for the year:

• Main member – R13, 512
• Adult dependants – R12, 792
• Children – R2, 688 (A maximum of three children are used in this calculation)

Word of warning:
Think of it as a line of credit. If you join halfway through the year, then you get half the MSA. If you decide to leave Discovery Health halfway through the year – and in between you’ve spent it all – then you have the privilege of paying back half of the MSA allocated to you.

Which brings us to the above threshold benefit.

The above threshold benefit is the hurdle you need to reach before Discovery Health starts picking up the bills after having run out of MSA.

• Main member – R15, 500
• Adult dependants – R15, 500 (notice that with the MSA being less for adult dependants than for the main member, it creates a larger self-payment gap)
• Children – R2, 950 (A maximum of three children are used in this calculation)

And here’s how the self-payment gap works for the main member:

• MSA for the year – R13, 512
• Main member above threshold benefit – R15, 500
• The difference between the two is your self-payment gap – R1, 988

Here’s how it compares to Executive:

But your potential self-payment gap could be much bigger because:

• Over-the-counter medicines (Schedule 0-2) obtained via prescription or any other means, are added to the self-payment gap – even if paid in full from your available MSA
• Schedule 3 and above medicines obtained via prescription – but which are on the non-preferred medicine list – are only included at 75% of the DHR. The remaining 25% of the DHR is added onto your self-payment gap.
• Schedule 3 and above medicines on the preferred list are included at 100% of the DHR, BUT your pharmacy may charge more and this gets added to your self-payment gap (That’s why Dischem and Clicks are preferred providers).
• You overspend on spectacles and dentistry. For instance, your annual limit for spectacles is R4, 600 per person. You purchase a pair for R5, 000 thereby creating a R400 gap.

Can you see how horribly wrong this can go?
You’re expecting to pay in R1, 988 and instead wind up with a R5, 000 gap. And remember to keep sending your medical bills to Discovery Health while in self-payment gap – how else will they know whether the gap is closing?

As usual, leave your comments below. In part six we take a look at the Discovery Health 2017 Classic Delta Comprehensive plan.

In case you missed the other Discovery Health 2017 articles:

• Part one – Discovery Health in a nutshell
• Part two – Where does KeyCare fit in?
• Part three – The Executive plan
• Part four – The Comprehensive plans

Do you need assistance with your medical aid?

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Until next time.

The InsuranceFundi Team