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 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 (DSP) Discovery Health Rate 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. Prescribed Minimum Benefits (PMB) Shortfall A set of minimum benefits that, by law, must be provided to all medical scheme members. The cover it gives includes the diagnosis, treatment and cost of ongoing care for a list of conditions. If a treatment that falls outside the defined benefits and is not approved, it will be paid for from the available benefits according to the member s chosen health plan. If the member s health plan does not cover these expenses, the member will be responsible to pay the unpaid claims. Discovery Health Medical Scheme pays service providers at a set rate, the Discovery Health Rate, which is a set rate. If the service providers charge higher fees than this rate, the member will have to pay the outstanding amount from his or her pocket. Cover for alcohol, substance and drug rehabilitation 2015 26 January 2015 Page 2 of 5
The Alcohol, Substance and Drug Rehabilitation Benefit We cover in-hospital 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, substance and drug, detoxification and rehabilitation are Prescribed Minimum Benefits, in terms of the Medical Schemes Act 131 of 1998 and will be covered. Discovery Health Medical Scheme has Designated Service Providers (DSP) for inhospital alcohol, substance and drug detoxification and rehabilitation All Discovery Health Medical Scheme s designated service providers for alcohol, substance and drug detoxification and rehabilitation services across South Africa are listed on page 5. We have an agreed rate that we pay DSPs and this includes cover for: Accommodation at the facility Therapeutic sessions Psychologist or psychiatrist consultations Medicine for withdrawal management and aftercare Go to page 5 for contact details for DSP facilities. Contact us For a detailed list of our designated service providers go to www.discovery.co.za/maps, or call us on 0860 99 88 77. 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. You need to authorise your admission for in-hospital 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. Members must get their in-hospital alcohol, substance and drug detoxification and rehabilitation treatment from our DSPs for full cover and to avoid co-payments 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 to 80% of the Discovery Health Rate. You will be liable to pay the difference. Your co-payment may be higher than 20% if your service provider charges more than the Discovery Health Rate. Cover for alcohol, substance and drug rehabilitation 2015 26 January 2015 Page 3 of 5
We will consider full payment in cases where there is no designated service provider If there is no designated service provider facility within a 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 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 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 twenty one days each year. This is the maximum allowable days for a member for the year. Members can choose to be in treatment for a period shorter than 21 days in consultation with a healthcare provider. 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 If you are admitted to a facility that is not one of our designated service providers for in-hospital 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. Important things to remember Discovery Health Medical Scheme does not cover out-of-hospital alcohol, substance and drug detoxification and rehabilitation as it is general scheme exclusion and is not included as part of the Prescribed Minimum Benefits. 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. Cover for alcohol, substance and drug rehabilitation 2015 26 January 2015 Page 4 of 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 that which 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 designated service provider facility close to you Eastern Cape 043 722 1210 SANCA Central Eastern Cape Eastern Cape Free State Aurora Alcohol and Drug Centre 051 447 7271 Gauteng East SANCA Horizon Elim Clinic 011 917 5015 011 975 2951 Gauteng North SANCA Pretoria Society 012 542 1121 Stabilis Treatment Centre 012 333 7702 Gauteng West Phoenix House 011 673 0400 / 086 117 3422 SANCA West Rand Alcohol and Drug Centre 011 472 7707 Gauteng South Nishtara Lodge 011 854 5988 KwaZulu-Natal SANCA Durban Alcohol and Drug Centres: Lulama Treatment Centre/ Warman House Adolescent Unit 031 202 2274/41 Mpumalanga Mkhondo Alathia Rehabilitation Centre 071 670 8536/7/8 North West Sanpark Alcohol and Drug Centre 018 462 4568 Western Cape Namaqua Treatment Centre 027 217 1144 Parow East The Ramot Treatment Centre 021 939 2033 Discovery Health Medical Scheme; registration number 1125, administered by Discovery Health (Pty) Ltd; registration number 1997/013480/07, an authorised financial services provider. In this brochure, the value-added service MaPS Advisor is owned by Discovery Health (Pty) Ltd. Scheme rules (found on www.discovery.co.za) apply at all times. Cover for alcohol, substance and drug rehabilitation 2015 26 January 2015 Page 5 of 5