Allied, Therapeutic and Psychology Benefit 2013

Transcription

1 Allied, Therapeutic and Psychology Benefit 2013

2 Allied, Therapeutic and Psychology Benefit The Allied, Therapeutic and Psychology Benefit is available on the Executive, Comprehensive Priority and Saver Plans only. For members on Saver Plans, cover is subject to the available funds in the Medical Savings Account. Overview This document tells you more about how the Allied, Therapeutic and Psychology Benefit works and how to apply for additional cover if you have a severe, complex conditions that require short or longterm assistance from allied, therapeutic and psychology healthcare professionals. About some of the terms we use in this document There are a number of terms we refer to in this document that you may not be familiar with. We give you the meaning of these terms. Terminology Allied, therapeutic and psychology healthcare professional Discovery Health Rate Above Threshold Benefit Description This is a registered medical professional other than a doctor or dentist who provides support services and/or rehabilitation services that are aimed at improving the physical, psychological, emotional, and social wellbeing of members. This is the rate that Discovery Health sets for paying claims from healthcare professionals and other services. This gives you further day-to-day cover when your Medical Savings Account runs out and when your day-to-day claims add up to a set rand amount. The Classic Comprehensive Zero MSA Plan does not have a Medical Savings Account and so there is no benefit for day-to-day medical expenses until you reach the Annual Threshold. After this, we pay claims from the Above Threshold Benefit. Page 2 of 7 12/2012

3 The Allied, Therapeutic and Psychology Benefit, at a glance We pay for out-of-hospital allied, therapeutic and psychology services from your dayto-day benefits We pay out-of-hospital allied, therapeutic and psychology healthcare services from your Medical Savings Account. When the money in your Medical Savings Account is used up and you have reached your Annual Threshold, you have cover from your Above Threshold Benefit. The Classic Comprehensive Zero MSA Plan does not have a Medical Savings Account and so there is no benefit for day-to-day medical expenses until you reach the Annual Threshold. After this, we pay claims from the Above Threshold Benefit. We pay for allied, therapeutic and psychology healthcare services up to an annual limit on the Executive, Comprehensive and Priority Plans Out-of-hospital allied, therapeutic and psychology healthcare services are covered up to an overall annual limit, which varies according to family size and plan type. Please refer to Benefits available on the different plan types on page 5 to see what the limit is for your health plan. We pay for certain allied, therapeutic and psychology healthcare professionals Cover from the Allied, Therapeutic and Psychology Benefit includes services from the following allied healthcare professionals: Acousticians Art therapists Biokineticists Chiropractors Counsellors Dietitians Homeopaths Occupational therapists Physiotherapists Podiatrists Psychologists (clinical, counselling, educational and industrial) Psychometrists Registered nurses Social workers Speech- language therapists and audiologists Applying for additional allied, therapeutic and psychology healthcare cover You can apply for cover on the Allied, Therapeutic and Psychology Extender Benefit On the Executive and Comprehensive Plans, the Allied, Therapeutic and Psychology Extender Benefit gives members who qualify for the benefit unlimited cover for a list of allied, therapeutic and psychology healthcare services without accumulation towards the annual family Allied, Therapeutic and Psychology Benefit limit. This benefit has been introduced to cater for members with severe, complex conditions who require short or long-term assistance from allied, therapeutic and psychology healthcare professionals. This unlimited cover is for a defined list of providers and conditions, such as quadriplegia and cerebral palsy, and cover depends on the member s condition and the criteria for it.we will only consider applications for additional cover from the following healthcare professionals: Acousticians Biokineticists Chiropractors Occupational therapists Psychologists (clinical, counselling, educational) Physiotherapists Speech- language therapists and audiologists Page 3 of 7 12/2012

4 You can apply for additional cover once you reach the Allied, Therapeutic and Psychology Benefit limit On the Executive, Comprehensive and Priority Plans, Discovery Health Medical Scheme also extends cover for allied, therapeutic and psychology healthcare services for members with conditions that need access to additional benefits above the limit, but whose conditions do not form part of the Allied, Therapeutic and Psychology Extender Benefit. Discovery Health, along with representatives of the relevant professional society, will review and evaluate the clinical circumstances of every member s application for additional benefits when they reach the Allied, Therapeutic and Psychology Benefit limit. This review will be based on our clinical protocols developed by Discovery Health Medical Scheme and the relevant society. Any member with genuine clinical need will gain access to additional benefits for a defined list of providers. We will only consider applications for additional cover from the following healthcare professionals: Acousticians Biokineticists Chiropractors Occupational therapists Psychologists (clinical, counselling, educational) Physiotherapists Speech- language therapists and audiologists We will not consider cover for both a chiropractor and physiotherapist for the same condition. Page 4 of 7 12/2012

5 Benefits available on the different plan types Executive Plan We pay for allied, therapeutic and psychology services from your day-to-day benefits We pay for out-of-hospital allied, therapeutic and psychology healthcare services from the available funds in your Medical Savings Account and from the Above Threshold Benefit once your claims add up to the Annual Threshold. We pay claims for allied, therapeutic and psychology healthcare professionals up to a maximum of 100% of the Discovery Health Rate. If your healthcare provider charges higher than this rate, you will need to pay the balance. We pay for allied, therapeutic and psychology healthcare services up to a limit The annual limits are: Single member R Member with one dependant R Member with two dependants R Member with three or more dependants R If you join the medical scheme after January, you won t get the full limit because it is calculated by counting the remaining months in the year. You have access to additional cover for allied, therapeutic and psychology services when the overall annual limit is reached The Allied, Therapeutic and Psychology Extender Benefit provides cover for members with severe, complex conditions, who need short- or long-term care from allied, therapeutic and psychology healthcare professionals. The unlimited cover is for clinically appropriate care, for a defined list of providers and conditions, such as quadriplegia and cerebral palsy. This means that cover depends on the member s condition and the criteria for it. The Allied, Therapeutic and Psychology Extender Benefit only covers acousticians, biokineticists, chiropractors, occupational therapists, physiotherapists, psychologists and speech-language therapists and audiologists. For more information on the Allied, Therapeutic and Psychology Extender Benefit, please refer to the 2013 Allied, Therapeutic and Psychology Extender Benefit document. Page 5 of 7 12/2012

6 Comprehensive Series We pay for allied, therapeutic and psychology services from your day-to-day benefits We pay for allied, therapeutic and psychology healthcare services from the available funds in your Medical Savings Account and from the Above Threshold Benefit once your claims add up to the Annual Threshold. The Classic Comprehensive Zero MSA Plan does not have a Medical Savings Account and so there is no benefit for day-to-day medical expenses until you reach the Annual Threshold. After this, we pay claims from the Above Threshold Benefit. We pay claims for allied, therapeutic and psychology healthcare professionals up to a maximum of 100% of the Discovery Health Rate, or at cost if you chose this option. These will add up to, and pay out from, your Above Threshold Benefit at 100% of the Discovery Health Rate once you reach your Annual Threshold. If you have run out of funds in your Medical Savings Account and have not yet reached your Annual Threshold (you are in the Self-payment Gap), you will need to pay these accounts. If your healthcare provider charges higher than this rate, you will need to pay the balance. We pay for allied, therapeutic and psychology healthcare services up to a limit The annual limits are: Classic Essential Single member R R6 600 Member with one dependant R R9 350 Member with two dependants R R Member with three or more dependants R R If you join the medical scheme after January, you won t get the full limit because it is calculated by counting the remaining months in the year. You have access to additional cover for allied, therapeutic and psychology services when the overall annual limit is reached The Allied, Therapeutic and Psychology Extender Benefit provides cover for members with severe, complex conditions, who need short- or long-term care from allied, therapeutic and psychology healthcare professionals. The unlimited cover is for clinically appropriate care, for a defined list of providers and conditions, such as quadriplegia and cerebral palsy. This means that cover depends on the member s condition and the criteria for it. The Allied, Therapeutic and Psychology Extender Benefit only covers acousticians, biokineticists, chiropractors, occupational therapists, physiotherapists, psychologists and speech-language therapists and audiologists. For more information on the Allied, Therapeutic and Psychology Extender Benefit, please refer to the 2013 Allied, Therapeutic and Psychology Extender Benefit document. Page 6 of 7 12/2012

7 Priority Series We pay for allied, therapeutic and psychology services from your day-to-day benefits We pay for allied, therapeutic and psychology healthcare services from the available funds in your Medical Savings Account or from the limited Above Threshold Benefit once your claims add up to the Annual Threshold. We pay claims for allied, therapeutic and psychology healthcare professionals up to a maximum of 100% of the Discovery Health Rate, or at cost if you chose this option. These will add up to, and pay out from, your limited Above Threshold Benefit at 100% of the Discovery Health Rate once you reach your Annual Threshold. If you have run out of funds in your Medical Savings Account and have not yet reached your Annual Threshold (you are in the Self-payment Gap), or when you reach your Above Threshold Benefit, you will need to pay these accounts. If your healthcare provider charges higher than this rate, you will need to pay the balance. We pay for allied, therapeutic and psychology healthcare services up to a limit The annual limits are: Classic Essential Single member R6 600 R4 400 Member with one dependant R9 350 R6 600 Member with two dependants R R8 250 Member with three or more dependants R R9 900 If you join the medical scheme after January, you won t get the full limit because it is calculated by counting the remaining months in the year. Saver Series We pay for allied, therapeutic and psychology services from your Medical Savings Account Claims for allied, therapeutic and psychology healthcare services are paid from the available funds in your Medical Savings Account. Once you run out of funds, you will need to pay these costs yourself. Core Series You are responsible for paying out-of-hospital claims for allied, therapeutic and psychology healthcare services as your plan does not have benefits for out-of-hospital medical expenses. KeyCare Series We do not cover allied, therapeutic and psychology healthcare services, including treatment from physiotherapists, psychologists, homeopaths, chiropractors, speech-language therapists and audiologists or acousticians. You are responsible for paying out-of-hospital claims for allied, therapeutic and psychology healthcare professionals. Page 7 of 7 12/2012