Discovery Health Core Series Product Platform
March 3, 2017
As one of South Africa’s leading medical aid fund manager, Discovery Health offers a wide range of plans and options for members. And while the plans vary from the KeyCare plan to the Executive plan, all the options cover the Prescribed Minimum Benefits (PMB) as prescribed by the Council for Medical Schemes (MSC). Here we will have a look at the Discovery Health Core Series.
What the Council says – Discovery Health Core Series
According to the Council, all medical aid schemes in South Africa should ensure that as a benefit to their members they provide for the diagnosis. Treatment and care of the consumer in case of a life-threatening emergency. Diagnosis of 270 diseases and conditions and treatment of 27 chronic illnesses or conditions. This requirement is included as benefits under the Prescribed Minimum Benefits in all schemes that medical aid fund managers provide as the very basic benefit.
The PMB – Discovery Health Core Series
Discovery Health has structured to pay out the PMB benefits out of their risk factor when their client gets medical attention for any of the listed ailments from a medical practitioner on their network of service providers. Discovery Health has established good working relations with these medical practitioners. Which result in well-negotiated rates that ensure consumers get excellent service at low cost. And while the member has the option of using other non-prescribed practitioners. They will benefit more from not having to make co-payments if they use prescribed practitioners.
To benefit from the PMB payment plan. Members need to ensure that their condition is listed as covered on their chosen plan. And that the prescribed treatment by the medical practitioner is as pre-set for that condition in the agreed treatment plan. If the treatment does not meet this criterion. Then Discovery Health pays out the claim to the maximum allowable according to their stipulated rate. And the member must pay the rest from their personal savings.
While Discovery Health will make payments above the rate stipulated by the law. They sometimes will pay only the PMB where a client is still within their plan activation waiting period. Or their chosen plan does not cover their condition treatment. If the customer joins the medical scheme more than 90 days after leaving their previous scheme. Or did not have previous medical cover before joining Discover. It will result in a waiting period which halts their immediate cover for PMB.
While Discovery Health will pay for PMB conditions from the risk pool and not the day to day benefits pool. Clients do need to register the conditions they suffer from and seek pre-authorization for certain procedures such as hospitalisation before they can pay out claims. Not registering the condition, unfortunately, results in the depletion of the members available day to day benefit as it is an ordinary condition.
All info was correct at time of publishing