Cover for alcohol, substance and drug rehabilitation

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1 Cover for alcohol, substance and drug rehabilitation 2013

2 How we cover alcohol, substance and drug detoxification and rehabilitation Overview This document gives you information about how Discovery Health Medical Scheme pays for alcohol, substance and drug detoxification and rehabilitation. You ll find information about how we pay for these treatments both in and out of hospital and who the network providers for these treatments are. 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 Designated service provider Discovery Health Rate Prescribed Minimum Benefits SANCA Description A healthcare provider (for example doctor, specialist, pharmacist or hospital) who we have an agreement with to provide treatment or services at a contracted rate. The rate that Discovery Health (Pty) Ltd sets for paying claims from healthcare professionals and other service providers. A set of conditions that all medical schemes must provide a basic level of cover for. This basic level of cover includes the diagnosis, treatment and costs of the ongoing care of these conditions. The South Africa National Council on Alcohol and Drug Dependence. SANCA is an organisation that addresses alcoholism and drug dependence through specialised, accessible and affordable developmental prevention and treatment services to all people, enhancing the quality of life and restoring the self respect and dignity of people affected by alcohol and drug dependence. Page 2 of 5 11/2012

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.

3 The Alcohol, Substance and Drug Rehabilitation Benefit, at a glance We cover alcohol, substance and drug detoxification and rehabilitation as a Prescribed Minimum Benefit Discovery Health Medical Scheme has certain exclusions that we do not pay for, except where stipulated under the Prescribed Minimum Benefits. Alcohol, substance and drug abuse is a general scheme exclusion. However, the in-hospital management of alcohol, drug, substance and alcohol detoxification and rehabilitation are Prescribed Minimum Benefits, in terms of the Medical Schemes Act 131 of Discovery Health Medical Scheme has designated service providers (DSP) for alcohol, substance and drug detoxification and rehabilitation All SANCA facilities across South Africa, Ramot Treatment Centre and Nishtara Lodge are Discovery Health Medical Scheme s designated service providers for alcohol, drug detoxification and rehabilitation services. The agreed rate we pay at our designated service providers includes: Accommodation Therapeutic sessions Psychologist or psychiatrist consultations Medicine for withdrawal management and aftercare For a detailed list of our designated service providers for alcohol, substance and drug detoxification and rehabilitation go to send an to healthinfo@discovery.co.za or call us on Members must get their in-hospital alcohol, substance and drug detoxification and rehabilitation treatment from our DSPs for full cover and to avoid copayments If you choose to use a facility that is not a designated service provider, we will pay for alcohol, substance and drug detoxification and rehabilitation up 80% of the Discovery Health Rate. You must pay the difference. Your co-payment may be higher than 20% if your service provider charges more than the Discovery Health Rate. We will consider full payment in cases where there is no designated service provider reasonably near to where the member lives or works If there is no designated service provider facility in reasonable proximity to the place where you usually work or live, you may use any other accredited service provider. Please discuss this with us when you contact us to preauthorise your treatment. We will tell you under what circumstances we pay the claims for alcohol and drug detoxification and rehabilitation in full without any co-payments. We cover in-hospital detoxification up to three days for each admission Discovery Health Medical Scheme covers alcohol, substance and drug detoxification in full at one of our designated service providers for a maximum of three days for each approved admission. We don t limit the number of admissions for detoxification as long as it is followed directly by rehabilitation. Page 3 of 5 11/2012

However, the in-hospital management of alcohol, drug, substance and alcohol detoxification and rehabilitation are Prescribed Minimum Benefits, in terms of the Medical Schemes Act 131 of 1998.

4 We cover in-hospital rehabilitation according to the Prescribed Minimum Benefit requirements Discovery Health Medical Scheme covers alcohol, substance and drug rehabilitation at one of our designated service providers for a maximum of 21 days each year, for each person. This is the maximum allowable days for a member for the year and does not mean that the admission for rehabilitation has to be 21 days. You do not have to be admitted for detoxification before being admitted for rehabilitation. We do not cover out-of-hospital alcohol, substance and drug detoxification and rehabilitation Cover for alcohol, substance and drug detoxification and rehabilitation according to the Prescribed Minimum Benefits includes only in-hospital management. Discovery Health Medical Scheme does not pay for the out-of-hospital management and treatment for detoxification and rehabilitation. Getting the most out of your benefits Use our designated service providers to avoid a co-payment All SANCA facilities across South Africa, Ramot Treatment Centre and Nishtara Lodge are Discovery Health Medical Scheme s designated service providers for alcohol, drug detoxification and rehabilitation services. If you are admitted to a facility that is not one of our designated service providers for alcohol, substance and drug detoxification and rehabilitation, you will need to pay the difference between what Discovery Health Medical Scheme pays and what the facility charges. You need to authorise your admission for alcohol, substance and drug detoxification and rehabilitation Please make sure you get authorisation for your admission for alcohol, substance and drug detoxification and rehabilitation. We will give you information about your cover as well as the closest designated service provider to you. Understand your benefits Discovery Health Medical Scheme does not cover out-of-hospital alcohol, substance and drug detoxification and rehabilitation as it is a general scheme exclusion. The Scheme will pay for a maximum of three days for each admission for alcohol, substance and drug detoxification. If you are admitted for alcohol, substance and drug detoxification, it must always be followed by an admission for rehabilitation. You have cover for a maximum of 21 days for rehabilitation for each person, each year. The Scheme will only cover your admission for treatment, if you are admitted to a facility that is appropriately registered and accredited to provide this specific treatment. Page 4 of 5 11/2012

This is the maximum allowable days for a member for the year and does not mean that the admission for rehabilitation has to be 21 days.

5 If you are admitted to a facility that is not a designated service provider for alcohol, substance and drug detoxification and rehabilitation, you may have a co-payment. You will need to pay the difference between what Discovery Health Medical Scheme pays and what the facility charges. If you do not authorise your admission before going into hospital, the Scheme will only pay up to 70% of the Discovery Health Rate for this admission. You will need to pay the balance. Find a SANCA facility close to you Eastern Cape SANCA Central Eastern Cape Free State Aurora Alcohol and Drug Centre Gauteng East SANCA Horizon Gauteng North SANCA Pretoria Society Stabilis Treatment Centre Gauteng West Phoenix House / SANCA West Rand Alcohol and Drug Centre Gauteng South Nishtara Lodge KwaZulu-Natal SANCA Durban Alcohol and Drug Centres: Lulama Treatment Centre/ Warman House Adolescent Unit /41 Mpumalanga Mkhondo Alathia Rehabilitation Centre /7/8 North West Sanpark Alcohol and Drug Centre Page 5 of 5 11/2012

If you do not authorise your admission before going into hospital, the Scheme will only pay up to 70% of the Discovery Health Rate for this admission. You will need to pay the balance.

Cover for alcohol, substance and drug rehabilitation

Cover for alcohol, substance and drug rehabilitation 2015 How we cover alcohol, substance and drug detoxification and rehabilitation Overview This document gives you information about how Discovery Health