Underwriting policies and protocols

Transcription

1 Underwriting policies and protocols 2015

2 Table of contents Introduction..3 Section 1 Medical scheme risk management..3 Section 2 Explanation of terms..4 Section 3 Late-joiner penalties.4 Section 4 Dependants.7 Section 5 Continuation options.11 Section 6 Underwriting.12 Section 7 Transferability.13 Section 8 Group underwriting...13 Section 9 New members joining a current employer group.. 20 Section 10 Simplified registration for Chronic Illness Benefit Underwriting policies and protocols February 2015 Page 2 of 21

3 Introduction This document about Discovery Health Medical Scheme s underwriting policies and protocols will help you understand how we categorise clients and how we apply underwriting according to these categories. It explains why and how late-joiner penalties may apply and it touches on member movement (when clients want to move from one employer group to another) and whether or not underwriting will apply. We explain how Discovery Health Medical Scheme defines a dependant and the requirements for underwriting dependants. We also give information about continuation options for members who have no break in cover. 1. Medical scheme risk management The Discovery Health Medical Scheme is a community-rated open-enrolment medical scheme, which means healthcare cover is offered at the same price for everyone. The number of dependants a member has on Discovery Health Medical Scheme determines the contributions. The same contributions apply to everyone regardless of age or health (children and adults pay different contributions). We allow members to change their health plans at the end of each year, with effect from 1 January of the next year. This table shows how we categorise your clients as individuals or size-based groups, our requirements and how we apply underwriting. Size Underwriting Underwriting decision Application forms Requirements Additions to membership/group Individuals One to nine main members Individual medical underwriting 12-month condition specific waiting periods, three-month general waiting period and late-joiner penalties may be applied Applying to become a member of Discovery Health Medical Scheme Questionnaires and requests for additional medical information as appropriate Individual underwriting decisions apply to each individual or member of a family Groups 10 or more main members Demographic underwriting, group decision Group decision will be applied, but individual underwriting decisions may apply to each member of the group (at our discretion) Joining as part of an employer group No questionnaires or requests for additional medical information (at our discretion) Individual underwriting decisions apply to each member of the group (at our discretion) Underwriting policies and protocols February 2015 Page 3 of 21

4 2. Explanation of terms A waiting period is the time period before a member can claim for healthcare services. Waiting periods such as a three-month general waiting period and a 12-month condition specific waiting period may apply. A late-joiner penalty is a percentage increase in a member s contribution and calculated as a percentage of the risk contribution. The late-joiner penalty is calculated using the member s age and the amount of creditable cover that the member has at the date of application. 3. Late-joiner penalties Discovery Health Medical Scheme may apply late-joiner penalties The Medical Schemes Act allows us to apply late-joiner penalties to an applicant or a dependant of an applicant who fits the definition of a late-joiner. Late-joiner penalties came into effect on 1 April Before that, the government gave everyone time to join medical schemes with no late-joiner penalties. This was called an amnesty period. The amnesty period ended on 31 March Who we consider a late-joiner applicant A late joiner is an applicant, or the dependant of an applicant, who at the date of application: is 35 years or older, and was not a member of or a dependant on a registered South African medical scheme (foreign schemes and insurance policies are not recognised) on or before 1 April 2001, or has allowed a break in cover of more than three months since 1 April How Discovery Health Medical Scheme works out a late-joiner penalty A late-joiner penalty will only apply to you if you are 35 years or older. To work out how much your late-joiner penalty will be, we will count how many years you have not been a member of a registered South African medical scheme since you turned 35, excluding any period of cover as a dependant under the age of 21. Please remember, for this calculation, the medical scheme or schemes you belonged to must be registered at the Council for Medical Schemes. You can visit to see if your medical scheme is or was registered. Underwriting policies and protocols February 2015 Page 4 of 21

5 The percentage in this table will be added to the contribution you pay for your risk benefits (used to pay, for example, hospital stays and chronic medicine). The extra percentage will not be added to the contribution for your Medical Savings Account. Number of years not a member of a registered medical scheme after age 35 1 to 4 years 5% 5 to 14 years 25% 15 to 24 years 50% 25 years and more 75% Late-joiner penalty Who this late-joiner penalty can apply to Individual members In all cases where members have not belonged to a registered South African medical scheme or allowed a break in cover of more than three months, and who are older than 35 years (read the section about how Discovery Health Medical Scheme works out the late-joiner penalty). Status D schemes In all cases where members have not belonged to a registered South African medical scheme or allowed a break in cover of more than three months, and who are older than 35 years (read the section about how Discovery Health Medical Scheme works out the late-joiner penalty). Group schemes Spouses and adult dependants who are older than 35 years and who join Discovery Health Medical Scheme after the main member, or who were not dependants on a previous medical scheme. Main members joining Discovery Health Medical Scheme more than three months after the main member s employment start date (read the section about how Discovery Health Medical Scheme works out the late-joiner penalty). Main members who do not join within the agreed group concession period. The late-joiner penalty will always apply to: Members and dependants on status D schemes New dependants added to existing Discovery Health Medical Scheme memberships Existing members and dependants of Discovery Health Medical Scheme transferring between Discovery Health Medical Scheme memberships. Underwriting policies and protocols February 2015 Page 5 of 21

6 In certain cases we will not apply the late-joiner penalty There are cases where we apply revised criteria for late-joiner penalties. This has been effective since 1 June Expatriates returning to South Africa The late-joiner penalty will not be applied if clients joining Discovery Health Medical Scheme: Are expatriates returning to South Africa within five years of leaving, and Were previously members of the Discovery Health Medical Scheme, and Left South Africa within three months of their last day of membership, and Join Discovery Health Medical Scheme within three months of being back in South Africa. We will need a copy of their passports and proof that they travelled abroad. Please note: If a member had a late-joiner penalty on their Discovery Health Medical Scheme membership before leaving to go abroad, the same penalty will apply when they join Discovery Health Medical Scheme again. Members can remain on Discovery Health Medical Scheme while working abroad If your clients are working abroad for an extended period (maximum five years), they can move to the lowest income band on the KeyCare Access Plan. As soon as they return to South Africa, they can upgrade to any plan, but only if they do so within three months of returning to South Africa. We will need a copy of their passports and proof that they worked overseas. Members under the age of 46 The late-joiner penalty will not be applied if: Members joining Discovery Health Medical Scheme are under the age of 46, and No members listed on the application have pre-existing conditions, and The late-joiner penalty percentage is equal to 5% or 25%. How the criteria is applied: The age criterion is applied per member The pre-existing condition criterion is applied per family The concession can be granted to any individual under the age of 46 with no pre-existing conditions where the late-joiner penalty is equal to 5% or 25% even if there is another applicant on the policy who is aged 46 and older. Important note: The late-joiner penalty concession will not be granted for the entire application if any member on the application has a pre-existing condition. Underwriting policies and protocols February 2015 Page 6 of 21

7 Members joining the KeyCare Plans The late-joiner penalty will not be applied if members joining Discovery Health Medical Scheme: Are joining a KeyCare Plan, and Are under the age of 50, and Earn less than R a month. Please note: All members listed on the application form or the addition of dependant form must be under the age of 50. Existing members of Discovery Health Medical Scheme who joined on or before 1 June 2009 For existing members of Discovery Health Medical Scheme, who joined on or before 1 June 2009, we will consider not applying the late-joiner penalty after review. Members and dependants have to meet all the requirements of the revised criteria for either expatriates, members under the age of 46 or if they joined a KeyCare Plan as explained. Please note that the late-joiner penalty concessions do not apply to members who are joining through a Status D employer group. 4. Dependants A dependant is: A member s spouse or partner who is not a member or a registered dependant of a member of a medical scheme A member s child who is not a member or a registered dependant of a member of a medical scheme The immediate* family of a member for whom the main member is liable for family care and financial support Such other persons who are recognised by the Board of Trustees as dependants for purposes of these rules An adult dependant (as defined below). *Immediate family is defined as first bloodline, that is, a child (including stepchildren), parents and siblings Underwriting policies and protocols February 2015 Page 7 of 21

8 Child dependants A member s natural child, a stepchild, legally adopted child or a child who has been placed in the custody of the member or his or her spouse or partner, by order of the court or a competent authority. Discovery Health Medical Scheme allows members to register their newborns free of underwriting if: the newborn is registered within three months of birth, and the cover start date is the same date as the newborn s date of birth. However, we recommend that members register their newborns within one month of birth. When a newborn is registered on Discovery Health Medical Scheme within one month of the birth: the newborn dependant will have immediate access to healthcare benefits offered on the health plan, and the member s contributions will be up to date, creating no concerns around financial implications. Please note: We need the newborn s ID number to add the child onto the membership. The rules to add an adopted and foster newborn are described below. Adding adopted children to an existing Discovery Health Medical Scheme membership Adopted newborn: If the adoption is still in progress, but we have received the Discovery Health Medical Scheme affidavits completed by the main member and the social worker within three months of the baby s birth, then the baby can be added from their date of birth, free of underwriting. If the adoption is final and legal proof is submitted, we can add the baby free of underwriting from their date of birth if we receive the application within three months of the baby s birth. Adopted child: If the application for an adopted child under the age of 18 to join Discovery Health Medical Scheme is sent to us within three months of the date of legal adoption, we will add the child to the adoptive parents membership free of underwriting with proof of legal adoption. If the application for an adopted child under the age of 18 to join Discovery Health Medical Scheme is sent to us after three months from the date of legal adoption, we will add the child to the adoptive parents membership and apply full underwriting with proof of legal adoption. Underwriting policies and protocols February 2015 Page 8 of 21

9 If the adoption for a child under the age of 18 is still in progress, we need the Discovery Health Medical Scheme affidavits completed by the main member and social worker or a letter from the social worker or courts confirming that the adoption is still in progress. In this case the child will be free of underwriting provided that the application is done within three months of the child being placed in the adoptive parents care. We would need a letter from the social worker or courts confirming the date that the child was placed in the adoptive parents care. The child must be added from the first of the month that they were placed in the care of the adoptive parents and Discovery Health Medical Scheme will not bill for the first month s premium. If the request to add the adopted child is received after three months from the adoption or from the child being placed in the care of the adoptive parents, full underwriting will apply with proof of legal adoption. Adding foster children to an existing Discovery Health Medical Scheme membership If the application for a foster child under the age of 18 to join Discovery Health Medical Scheme is sent to us, we will add the child to the foster parents membership and apply full underwriting. An application for a foster child must be accompanied by supporting legal documentation. Adding stepchildren to an existing Discovery Health Medical Scheme membership Certain criteria apply when allowing stepchildren to be added to a membership where the biological parent is not on the membership or part of the application. In these instances we need the following documentation: A legal marriage certificate to confirm that the main member is a legal spouse to the child dependant's biological parent, and An unabridged birth certificate. The unabridged birth certificate contains both parents' names, surnames and ID numbers. This information will allow us to confirm that the principal member's spouse is the biological parent of the stepchild. Adding grandchildren to an existing Discovery Health Medical Scheme membership A grandchild can only be a dependant on a membership if: there is at least one biological parent of the grandchild on the policy or part of the new business application, and the biological parent is eligible as per the child or adult dependant eligibility criteria of Discovery Health Medical Scheme; or the grandparents have proof of legal adoption, legal guardianship or foster arrangement for the grandchild. In this instance, proof of legal documentation is required. Underwriting policies and protocols February 2015 Page 9 of 21

10 Adding adult dependants to an existing Discovery Health Medical Scheme membership An adult dependant is a person, other than the spouse or partner, who is wholly or partly dependent on a member for financial support and who is registered in terms of Discovery Health Medical Scheme rules as an adult dependant and includes, but is not limited to: The divorced spouse of a member The relative, whether by affinity or blood (first bloodline), of a member The second spouse of a member under a customary union or a union recognised as a marriage by any religion or custom A person with whom the member has a relationship similar to the relationship of legally married spouses. More information on adult dependants 1. Maximum entry age of adult dependants Discovery Health Medical Scheme has no maximum entry age. 2. Eligibility for adult dependants The underwriters reserve the right to investigate the eligibility of adult dependants. Eligibility is assessed on: o Disclosed financial dependency and income, and o Relationship. In the case of a divorced spouse of a member, we require a divorce settlement agreement to confirm that the main member is financially responsible for the ex spouse s medical aid. 3. Group underwriting for adult dependants If the adult dependant forms part of the same application as the main member, and the main member qualifies for group underwriting then the adult dependant will also qualify for group underwriting (if eligible). The underwriters reserve the right to investigate the eligibility of adult dependants. Any adult dependants added after the start date of a membership will be subject to individual underwriting, and an addition of a dependant application form will have to be completed for them. For group underwriting, members who were permitted as adult dependants on their previous scheme (before joining Discovery Health Medical Scheme with a break in membership of less than three months), will be permitted to keep their adult dependant status on Discovery Health Medical Scheme. A copy of their previous membership certificate must be attached. Underwriting policies and protocols February 2015 Page 10 of 21

11 Adding a spouse to an existing Discovery Health Medical Scheme membership A spouse is a person married to the main member or in a union in accordance with any law or custom recognised in South Africa. The addition of a spouse to an existing membership means that the spouse will be fully underwritten, subject to the following underwriting guidelines: A newly-wed spouse will be accepted free of underwriting if he or she provides a copy of the marriage certificate or proof that the marriage was registered. This includes civil union and customary marriages or under the tenets of any religion. This needs to be done within three months of the date of the registered marriage or civil union. The addition of a common-law spouse will be subject to underwriting. For the second spouse of a member under a customary union or a union recognised as a marriage by any religion or custom, we require a copy of the marriage certificate or proof that the marriage was registered. 5. Continuation options Existing members can continue their Discovery Health Medical Scheme memberships on the same terms and conditions, without providing extra medical evidence that applied during the main member s membership. If there has been a break in membership, full underwriting will apply. Members and dependants can make use of the continuation option in the following events: Retirement from employment Subject to the conditions of the member s employment agreement, the member may remain on Discovery Health Medical Scheme when they retire Death of the main member Divorce A dependant who becomes financially independent A child dependant, who becomes a self-supporting adult and moves to his or her own Discovery Health Medical Scheme membership. Movements by the member If members belong to an employer group and they want to move from one employer group to another, we may apply underwriting. This depends on the reasons for the movement in terms of the Medical Schemes Act. We will not apply underwriting to existing Discovery Health Medical Scheme members moving from one employer group to another if they have been on Discovery Health Medical Scheme for three months or longer without a break in membership. Plan upgrades will not be allowed for members that are granted Continuation. Please refer to the Plan Matrix on to see the plan moves allowed during the year. Underwriting policies and protocols February 2015 Page 11 of 21

12 6. Underwriting Individual members, addition of dependants, groups or members who join compulsory employer groups late (three months after the date of employment) and who are subjected to underwriting, are divided into three categories for underwriting purposes based on the Medical Schemes Act: Category A Category B Category C Members who have applied to join Discovery Health Medical Scheme but have not belonged to a registered South African medical scheme and members who have allowed a break of more than three months since ending their membership with the previous medical scheme. Members who have belonged to a registered South African medical scheme for a period of less than two years and have applied to join Discovery Health Medical Scheme less than three months since the date of ending their membership with the previous medical scheme. Members who have belonged to a registered South African medical scheme for a period of two years or more and have applied to join Discovery Health Medical Scheme less than three months since the date of ending their membership with the previous medical scheme. We may apply the following underwriting decision depending on the medical information given in the application form, or as requested by Discovery Health Medical Scheme: Category A Category B Category C A three-month general waiting period and a 12-month condition specific waiting period, if applicable. The member will not be covered under Prescribed Minimum Benefits. A 12 month condition-specific waiting period. If the previous medical scheme placed a general or conditionspecific waiting period on a membership and the waiting period did not expire at the date of ending their membership with the previous medical scheme, the remainder of the waiting period may apply. The member will be covered under Prescribed Minimum Benefits. A three-month general waiting period. The member will be covered under Prescribed Minimum Benefits. Late-joiner penalties may apply. Late-joiner penalties may apply. Late-joiner penalties may apply. Underwriting policies and protocols February 2015 Page 12 of 21

13 7. Transferability Transferability is when a member moves from a closed medical scheme to an open medical scheme without being subject to underwriting. The start date of the new membership needs to be within three months from leaving the closed scheme. The applicant must be forced to leave the closed scheme under the following circumstances: Due to the change of employment or retrenchment Due to the death of the principal member on the closed scheme. We require the death certificate and a membership certificate as proof in such a case Due to divorce. If the applicant was a spouse on a previous medical and is now changing from the previous closed medical scheme. The date of divorce must be three months or less from the date of commencement requested on the Discovery Health Medical Scheme application form. We require a copy of the divorce decree as proof of the date of the divorce. 8. Group underwriting A group underwriting concession is given to compulsory groups of 10 or more members who join Discovery Health Medical Scheme, but subject to the group underwriting criteria. Some of the benefits of a group decision are that members of the group will not have waiting periods before they can use benefits and late-joiner penalties will be waived on their Discovery Health Medical Scheme memberships. Process flow for a new group concession The following outlines the requirements for a group underwriting concession and the process to apply for a group underwriting concession: Requirements Discovery Health Medical Scheme issues group decisions and terms to employers applying for cover for 10 or more employees, for whom it is compulsory by their employer s definition to join the Discovery Health Medical Scheme. The employer will determine the compulsory nature of membership with Discovery Health Medical Scheme for its employees. The employer may change this compulsory definition, provided they send up-to-date information to Discovery Health Medical Scheme. In some instances this change may result in a change in the group underwriting status. All information communicated to Discovery Health Medical Scheme must be on a company letterhead and a new employer application form must be completed. Underwriting policies and protocols February 2015 Page 13 of 21

14 Examples of compulsory definitions The employer may require all employees to join the Discovery Health Medical Scheme or the membership may be compulsory for only a section of employees. Examples of where membership is compulsory for only a section of employees are: membership allowed only for current and future salaried employees, or membership allowed only for all current and future administrative employees. Based on the specific compulsory definition the employer supplies, any employees outside of the defined group applying for Discovery Health Medical Scheme membership will be subject to full individual underwriting and late-joiner penalties. For example, where membership is compulsory for all current and future administrative employees and an employee working in a different division applies for membership, Discovery Health Medical Scheme will apply full underwriting and late-joiner penalties. The employer application form All sections of the employer application form must be completed in full. Special attention must be given to the following information: The company s total number of employees The total number of employees who are joining Discovery Health Medical Scheme A compulsory definition of the employees who will be joining Discovery Health Medical Scheme (compulsory membership). This will determine which future employees will be issued automatic acceptance and which future employees will have underwriting. The compulsory definition could be specific to any one of the following: o Probation periods (members should join within three months from when this period starts) o The number of temporary and permanently employed employees o Long- or short-term contracts o Salary bands for compulsory membership (the salary an employee must earn to join Discovery Health Medical Scheme) o Job levels and grades A statement about compulsory membership of Discovery Health Medical Scheme for current employees (total number to join) A statement indicating whether or not Discovery Health Medical Scheme is compulsory for future employees. By using the above information, Discovery Health Medical Scheme can enforce the employer s contractual agreements in terms of medical scheme membership. Underwriting policies and protocols February 2015 Page 14 of 21

15 Demographics and industry The following information must be sent to the Underwriting Department for a decision on an employer group request: All demographic information see below Industry information and a short description of the employer group, for example, a company with 70 employees, for whom it is compulsory to join Occupation breakdown of employees, for example, administrative employees, sales employees or a combination of both. The address for group underwriting is: [email protected] To get a demographic report The employer must complete a Quotation and demographics request form. The form must contain the following information for each employee who wants to join Discovery Health Medical Scheme: Company name Industry Number of employees (split by occupational category) Date of birth of main member, spouse and adult dependants The number of children to be included for each main member The demographics and quotation request form with all the information must be ed to the Quotations Department at [email protected] Once the demographics report is received, it must be ed to group underwriting at [email protected] Underwriting Once all the information has been sent to the Underwriting Department, the demographics will be assessed taking into consideration the following: employer s industry, the occupation of employees and the group s profile, which includes average age, family size and the percentage of pensioners. The Underwriting Department will then approve or decline your group underwriting concession request. You will be issued with a letter regarding the outcome of the decision. If the group is not accepted, the employer and members may still join Discovery Health Medical Scheme as an individual employer subject to full underwriting and late-joiner penalties. It will take approximately 24 hours from when we receive the information for an underwriting decision to be made. Underwriting policies and protocols February 2015 Page 15 of 21

16 The group acceptance letter When a group concession is granted, the acceptance letter will be sent to the financial adviser. The acceptance letter must be signed by the company s representative, confirming acceptance of the terms and conditions set out in the letter. The signed acceptance letter must be attached to a completed employer application form and sent to the New Business Department for processing. The details on the employer application must match the details on the letter of acceptance, for example the defined group and the number of employees. We will confirm the company s membership starting date. New business processing When we receive the signed acceptance letter and a fully completed employer application form, our New Business Department will capture the employer s details and send the information to the Underwriting Department. Underwriting will confirm the status and update all the information, including the employer decision. Once underwriting has updated the employer to a group, an employer number will be issued. Please ensure that the employer number is indicated on all the member application forms, which can now be processed. Please note: We will process the applications but only activate the membership once we have the following number of applications: For groups of more than 35 employees we need 70% of the group employee application forms For groups of less than 35 employees we need 100% of the group employee application forms For Status D employers we need 100% of the group employee application forms Addition of new members to existing employer groups When sending application forms for a new employee who is joining an existing employer group, the employee s date of employment must be completed. If incomplete on the application form, the date of employment has to be confirmed on an employer letterhead, which must be signed and dated by the employer. Proof of the date of employment in the form of the employee s letter of appointment may also be required. If the applicant was employed more than three months before applying for membership, confirmation of why the employee is joining after this period will be requested. This must be completed in the About your employer section of the Joining as part of an employer group application form or confirmed on an employer letterhead. If the reason for joining late is not valid, the applicant will be subject to full underwriting and late-joiner penalties. A member application form must then be completed including the medical details section and previous medical scheme membership details. The member application form has to be signed and dated by the applicant. Underwriting policies and protocols February 2015 Page 16 of 21

17 Examples of valid reasons for an applicant not applying for membership within three months of the date of employment include: When a temporary employee becomes a permanent employee they must join Discovery Health Medical Scheme within three months of the permanent employment date. The date of permanent employment must be completed in the About your employer section of the Joining as part of an employer group application form and signed by HR or confirmed on a company letterhead. When a contracted employee becomes a permanent employee they must join Discovery Health Medical Scheme within three months of the permanent employment date. The date of permanent employment must be completed in the About your employer section of the Joining as part of an employer group application form and signed by HR or confirmed on a company letterhead. Previous cover under the spouse s membership where the applicant: o Is an employee who joins Discovery Health Medical Scheme within 3 months of divorce and they provide proof that they have been on the spouse s medical aid since the employer was granted a group underwriting concession, or o Is an employee who joins Discovery Health Medical Scheme within 3 months of their spouse/partner s resignation or retrenchment from their current employment and they provide proof that they have been on the spouse s medical aid since the employer was granted a group underwriting concession, or o Is an employee who joins Discovery Health Medical Scheme within 3 months of the death of their spouse/partner and they provide proof that they have been on the spouse s medical aid since the employer was granted a group underwriting concession. Increased salary or change in job grade - if the employer has defined the group underwriting concession according to salary bands or job grades and the employee has a change in salary or job grade which meets the defined compulsory nature; the employee must join within three months of the change in salary or job grade Promotion If previously excluded from the defined group of employees but is now promoted to a job which meets the defined compulsory nature; the employee must join within three months of promotion To avoid any delays in the processing of applications, it is preferable that all of the above information is sent together with the application form or provided in the About your employer section of the Joining as part of an employer group application form or on a company letter head. If this is done, each application form can be processed with no additional requirements and no delays. Underwriting policies and protocols February 2015 Page 17 of 21

18 Reviewing an employer s group underwriting concession An employer s employees may increase, which means that the employer s group underwriting concession can be reviewed. If there are 10 or more active employees or where an employer needs to review their current group decision, the following information has to be sent to Underwriting for consideration: A letter from the employer requesting a review of their employer status with confirmation of the compulsory nature of the employer An up-to-date employer application form with specific reference to the section titled Details of your company s employees of the employer application form A demographic report of current active members. This should be requested from the Quotations Department at: [email protected] The underwriter will take the claims history and other relevant history of the active members into account for review purposes and may request a loss ratio report. It will take approximately 24 hours from when we receive the information for an underwriting decision to be made. Amalgamation of two or more current employer groups Two or more employer groups may amalgamate or join Discovery Health Medical Scheme under one employer as a result of a buy-out or an acquisition. The following information has to be submitted to the [email protected] for consideration: A letter from the employer confirming the group s amalgamation as well as the reason for the amalgamation A letter from the employer requesting a review of their group decision with confirmation of the compulsory nature of the employer. An up-to-date employer application form with specific reference to the Details of your company s employees section of the employer application form, A demographic report of current active members under each employer group, and a combined report of active members of the employer groups together. This may be requested from the Quotations Department at: [email protected] It will take approximately 24 hours from when we receive the information for an underwriting decision to be made. Breakaways When certain divisions of a company want to break-away from an existing employer group to form their own employer group, this can be done. The group underwriting concession will not be an automatic decision. Underwriting policies and protocols February 2015 Page 18 of 21

19 The employer will need to have a review done on all of the divisions breaking away and the remaining members. The following information must be submitted to [email protected] Employer application form for the breakaway section of the business A demographic report for the breakaway employer and a demographic report for the employees remaining on the current employer group Letter from the employer explaining the breakaway and requesting a group underwriting concession. It is important to note that both employers must still fit the group criteria in order to retain the group status. Secondment agreement A secondment agreement can be put in place where an employer already has a group underwriting concession and employees are seconded abroad for a period of time, due to work contracts in other countries. The following requirements and information has to be sent to the Underwriting Department for consideration: Employer must be an existing compulsory group Employees must go abroad for work-related contracts The employer s group underwriting concession must be compulsory to rejoin the Discovery Health Medical Scheme on their return We require a letter from the employer requesting the secondment agreement and the following information: o the total number of employees seconded on a yearly basis o the countries to which employees will be seconded to o the average duration of their contracts whilst abroad and o confirmation of the compulsory nature of the employer group. The necessary documentation must be submitted with the member application form on the employee s return A demographic report must be included with the request. If the secondment agreement is granted, employees may resign from Discovery Health Medical Scheme for the period abroad and apply for membership again within one month of returning. We need a letter from the employer confirming the secondment details and proof of the date of return in the form of a copy of the member s passport. If an employee is contracted for three months or less, we advise them to remain on Discovery Health Medical Scheme as the employee will be covered under the International Travel Benefit or Africa Benefit, provided the employee is on a health plan that offers these benefits. Underwriting policies and protocols February 2015 Page 19 of 21

20 9. New members joining a current employer group An employer group may want to offer Discovery Health Medical Scheme memberships to employees who fall outside their defined compulsory definition. This can be done either because of acquisition or amalgamation of companies. The following information has to be sent to [email protected] for consideration: A letter from the employer, with information about the employees and confirmation of whether or not membership will be made compulsory for these employees A demographic report of current active members under the employer group, a demographic report of new employees and a combined demographic report of current active members and new employees. This may be requested from the Quotations Department at: [email protected] It will take approximately 24 hours from when we receive the information for an underwriting decision to be made. Summary of group underwriting concession Applies to employers of ten or more main members A fully completed employer application form must be submitted Applies where the employer specifies that membership with Discovery Health Medical Scheme is compulsory Demographic information, as supplied by the Quotations Department, has to be submitted Industry and occupation of employees will be considered Accepted or declined decisions will be communicated in writing. Please note: All reviews and new requests must be initiated by the group s financial adviser as these decisions are not automatically granted. 10. Simplified registration for Chronic Illness Benefit The automatic Chronic Illness Benefit approval is for employees who have an approved chronic condition and receive cover for chronic medicine from the medical scheme they belonged to before joining Discovery Health Medical Scheme. The condition must be on our list of covered chronic conditions and the approved medicine will be covered according to the rules of the member s Discovery Health Medical Scheme Plan. The requirements to qualify for automatic approval To qualify for automatic Chronic Illness Benefit approval, the employer group needs to meet these two requirements: Underwriting policies and protocols February 2015 Page 20 of 21

21 The employer group must have more than 75 employees joining the Discovery Health Medical Scheme. The employer group must qualify for a group underwriting concession or be a compulsory employer group. If an employer group does not meet these requirements, their employees who have chronic conditions will have to follow the standard process of applying for cover from the Chronic Illness Benefit. The information you need to send if the group qualifies for automatic approval Only send us the details for employees who currently take chronic medicine approved by the medical scheme they are currently members of. You cannot include new conditions. You can send the information in a spreadsheet. Please send it to us at least one month before these employees join Discovery Health Medical Scheme. Please include the following: Identity number and date of birth of the main member Identity number and date of birth of the person registered to receive chronic medicine For children with no identity document, we need the child s first name, last name and date of birth ICD-10 code for the chronic condition Name, strength and Nappi code for the approved medicine Dosage and quantity used each month The practice number of the healthcare professional who prescribed the chronic medicine Employer name. The above should be obtained from the previous scheme administrator. Should this not be available then members should complete the CIB Simplified application form. Where to send the information You can send the spreadsheet with the necessary information by to [email protected] Contact us You can call us on , or visit the website on for more information. Discovery Health Medical Scheme; registration number 1125, administered by Discovery Health (Pty) Ltd, registration number 1997/013480/07, an authorised financial services provider. Underwriting policies and protocols February 2015 Page 21 of 21