Allied and Therapeutic Extender Benefit

Transcription

1 Allied and Therapeutic Extender Benefit 2012

2 Allied and Therapeutic Extender Benefit The Allied and Therapeutic Extender Benefit is available on the Executive and Comprehensive Plans only. Overview This document tells you about the Allied and Therapeutic Extender Benefit. Read further to understand how the benefit works and details about the process to follow to apply for the Allied and Therapeutic Extender Benefit. Understanding some of the terms we use in this document There are a number of other terms we refer to in the document that you may not be familiar with. We give you the meaning of these terms. Terminology Allied healthcare professional Discovery Health Rate Above Threshold Benefit Description An allied healthcare professional is a registered medical professional other than a doctor or dentist who provides supportive and/ or rehabilitative services which are aimed at improving the physical, psychological, emotional, and social well being of members. This is the rate that Discovery Health sets for paying claims from healthcare professionals and other services. The Above Threshold Benefit 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.

3 The Allied and Therapeutic Extender Benefit, at a glance The Allied and Therapeutic Extender Benefit gives members on the Executive and Comprehensive Plans access to unlimited cover when the overall annual limit for allied and therapeutic services is reached The Allied and Therapeutic Extender Benefit provides cover for members with severe, complex conditions, who need short- or long-term care from allied and therapeutic healthcare professionals. Members who meet the benefit entry requirements have unlimited cover Members must meet the benefit entry requirements for the Allied and Therapeutic Extender Benefit. Those who meet the requirements for a specified list of conditions or treatment, have unlimited cover for certain allied healthcare professionals. There are two types of cover on the Allied and Therapeutic Extender Benefit Members who meet the requirements for the Allied and Therapeutic Extender Benefit can have cover for: the remainder of the year of the event and the following year once the annual limit on the Allied and Therapeutic Benefit is reached the remainder of the year in which the benefit was approved and every year thereafter once the annual limit on the Allied and Therapeutic Benefit is reached. Only certain allied providers are covered on the Allied and Therapeutic Extender Benefit The Allied and Therapeutic Extender Benefit covers services from biokineticists, hearing aid acousticians, physiotherapists, psychologists, occupational therapists and speech and audiology therapists. How we pay allied healthcare accounts We pay accounts funded from the Allied and Therapeutic Extender Benefit at 100% of the Discovery Health Rate. If you have run out of funds in your Medical Savings Account and have not yet reached your Annual Threshold (Self-payment Gap), you will need to pay these accounts. If your healthcare provider charges higher than the Discovery Health Rate, you will need to pay the balance yourself.

4 Conditions covered on the Allied and Therapeutic Extender Benefit These are the conditions and procedures which will be covered on the Allied and Therapeutic Extender Benefit 1. If you are on an Executive or a Comprehensive Plan, you have cover from the Allied and Therapeutic Extender Benefit in the year in which you were diagnosed with one of the following conditions, as well as the year following the diagnosis: Condition Hemiplegia and paraplegia Neonate born at <34 weeks gestation and/or <2 499 grams Neonates born with congenital disorders including cardiac, gastrointestinal, endocrine, neurological or other congenital abnormalities (including cleft palate) You must have been a Discovery Health member at the time of your diagnosis Baby born at less than 34 weeks gestation and/or baby born weighing less than grams Baby must be born onto the Discovery Health Medical Scheme Baby born with congenital abnormalities Baby must be born onto the Discovery Health Medical Scheme 2. If you are on an Executive or a Comprehensive Plan, you have cover from the Allied and Therapeutic Extender Benefit in the year in which you underwent the following procedure, as well as the year following the procedure: Procedure Hearing aid fitted in child 12 years or younger. Cochlear implant Voice synthesizer insertion or speech and audiology therapist Child 12 years or younger at the time the hearing aid was inserted Child must be on the Discovery Health Medical Scheme at the time when the procedure took place Member must be on the Discovery Health Medical Scheme at the time when the procedure took place Child must be on the Discovery Health Medical Scheme at the time when the procedure took place

5 3. If you are on an Executive or a Comprehensive Plan, you have cover from the Allied and Therapeutic Extender Benefit on an ongoing basis once your annual Allied and Therapeutic Benefit limit has been depleted, provided you have registered through our Chronic Illness Benefit for the following conditions: Condition Quadriplegia Motor neuron disease Parkinson s disease (and other movement disorders of the basal ganglia) Multiple sclerosis (and other demyelinating CNS disorders) Bronchiectasis (any cause including cystic fibrosis) Pulmonary interstitial fibrosis Muscular dystrophy (and hereditary muscular disorders) Connective tissue disorders: Rheumatoid arthritis Systemic lupus erythematosus Sjögren s syndrome Systemic sclerosis Overlap syndrome Juvenile chronic arthritis Ankylosing spondylitis Psoriatic arthritis Register for the condition on the Chronic Illness Benefit 4. If you are on an Executive or a Comprehensive Plan you have cover from the Allied and Therapeutic Extender Benefit on an ongoing basis, once your annual Allied and Therapeutic Benefit limit has been depleted for the following conditions: Condition Autism Cerebral Palsy Hereditary ataxias Spinal muscular atrophy Idiopathic pulmonary fibrosis Diffuse pulmonary fibrosis Fibrosing alveolitis Hamman-Rich syndrome Down s syndrome Application completed by physician, neurologist, psychiatrist or paediatrician (in the case of a child) Application completed by physician, neurologist, physician or paediatrician (in the case of a child) Application completed by physician, neurologist or paediatrician (in the case of a child) Application completed by physician, neurologist or paediatrician (in the case of a child) Application completed by physician, pulmonologist or paediatrician (in the case of a child) Application completed by your treating doctor Member must either be born on to the Scheme or have been a Discovery Health member before 1 January 2011

6 How to apply for the Allied and Therapeutic Extender Benefit in 2012 The latest version of the application from is available on Alternatively, members can call us on and healthcare professionals can call to request a form. Fax the completed application form to , it to clinicalhelp@discovery.co.za or post it to Discovery Health, PO Box , Sandton, 2146.