Trauma Recovery Extender Benefit 2012
We pay for ongoing intensive day-to-day care from the Trauma Recovery Extender Benefit
The Trauma Recovery Extender Benefit is available on Executive, Comprehensive, Priority, Saver and KeyCare Plus Plans. Core Plans do not offer day-to-day cover and so members on Core Plans do not have access to the Trauma Recovery Extender Benefit.
These are the typical day-to-day costs this benefit pays for:
| Professional medical services | GP and specialist consultations, including psychiatrists |
| Allied and therapeutic healthcare services | Biokineticists Chiropractors Counsellors Dietitians Acousticians Homeopaths Occupational therapists Physiotherapists Podiatrists Psychologists Psychometrists Registered nurses Social workers Speech and hearing therapists |
| Prescribed medicine, schedule 3 and above | Schedule 3 and above prescribed medicine |
| Radiology and pathology | Includes x-rays and scans and blood tests and other tests done in a laboratory |
| Medical devices and limb prostheses | External devices including wheelchairs and hearing aids and artificial legs and arms |
This is how the benefit works
Members must meet the clinical entry criteria to access cover on the Trauma Recovery Extender
The Trauma Recovery Extender Benefit covers certain day-to-day medical costs that result from any of the following:
| Trauma condition | To qualify for the benefit |
|---|---|
| The condition must require an ICU stay of five days or more |
| Paraplegia (paralysis of the lower half of the body affecting both legs, due to blunt force injury to the spinal cord) | There must be severe lessening of the strength or effectiveness of the limbs, shown by loss of reflexes, numbness and loss of motion in the spine. We use Beta or FIMS* score indications to measure the severity of the physical trauma. |
|
Quadriplegia (paralysis of both arms and legs due to blunt force injury to the spinal cord) |
|
|
Severe burns |
15% of the surface area must have full thickness burns. |
|
External and internal head injuries | The condition must require an ICU stay of five days or more. We use Beta or FIMS* score indications to measure the severity of the physical trauma. |
|
Loss of limb due to direct blunt force trauma |
Trauma-related loss of limb |
*Functional Independent Measure Scale – a universal measure of activities of daily living.
Members who qualify have automatic access to the Trauma Recovery Extender Benefit
Members will have automatic access to this benefit if they you meet the entry criteria. The benefit will be activated after the member has been admitted for one of the specific traumas and after the event has been appropriately reviewed and benefits approved.
Out-of-hospital claims related to the trauma event will be paid from the Trauma Recovery Extender Benefit and not the member’s day-to-day benefits
Once a member is on the Trauma Recovery Extender Benefit, certain claims linked to the trauma event won’t be paid from the Medical Savings Account. Instead, we will fund these claims from the Trauma Recovery Extender Benefit. This helps preserve the money in the member’s Medical Savings Account.
We pay these claims from the Trauma Recovery Extender Benefit for the rest of the calendar year in which the trauma happened and in the following year. Members will not qualify for the Trauma Recovery Extender Benefit if the trauma event occurred in a previous benefit year while on a plan type that did not offer this benefit or while they were a member of another medical scheme. Members have to be a member of the Discovery Health Medical Scheme at the time that the trauma occurs to qualify for cover from the Trauma Recovery Extender Benefit.
The day-to-day limits that apply to claims paid from the day-to-day benefits also apply to the Trauma Recovery Extender Benefit
This includes prescribed medicine, medical devices and allied and therapeutic healthcare services.
This is not a separate benefit, which means that claims for medicine, allied and therapeutic healthcare services (other than acousticians, biokineticists, physiotherapists, psychologists, speech and hearing therapists and occupational therapists), hearing aids and external medical items from the day-to-day benefits and the Trauma Recovery Extender Benefit add up to the one limit. The annual limits are:
|
| Medicine | Allied and therapeutic healthcare services | External medical items | Hearing aids | ||||||
| Executive Plan | Single member | R20 800 | Single member | R12 500 | Annual family limit of R45 500 | Annual family limit of R16 700 | ||||
| M+1 | R24 300 | M+1 | R15 000 | |||||||
| M+2 | R27 850 | M+2 | R17 500 | |||||||
| M+3 | R31 400 | M+3 | R21 000 | |||||||
| Comprehensive Plans |
| CLASSIC | ESSENTIAL | CLASSIC | ESSENTIAL | CLASSIC | ESSENTIAL | CLASSIC | ESSENTIAL | |
| Single member | R16 900 | R10 950 | Single member | R10 000 | R6 000 | Annual family limit of R45 500 | Annual family limit of R30 250 | Annual family limit of R16 700 | Annual family limit of R13 500 | |
| M+1 | R23 050 | R13 250 | M+1 | R13 500 | R8 500 | |||||
| M+2 | R16 500 | R15 950 | M+2 | R16 500 | R11 000 | |||||
| M+3 | R26 300 | R17 450 | M+3 | R19 000 | R13 000 | |||||
| Priority Plans |
| CLASSIC | ESSENTIAL |
| CLASSIC | ESSENTIAL | CLASSIC | ESSENTIAL | CLASSIC | ESSENTIAL |
| Single member | R10 950 | R7 800 |
| R6 000 | R4 000 | Annual family limit of R30 250 | Annual family limit of R20 500 | Annual family limit of R13 500 | Annual family limit of R9 600 | |
| M+1 | R13 250 | R9 200 | R8 500 | R6 000 | ||||||
| M+2 | R15 950 | R10 950 |
| R11 000 | R7 500 | |||||
| M+3 | R17 450 | R13 250 |
| R13 000 | R9 000 | |||||
If the member joins the Scheme after 1 January, they won’t get the full limit for prescribed medicine and allied and therapeutic healthcare services because these limits are calculated by counting the remaining months in the year.
We pay for prosthetic limbs up to an annual limit
On all plans, we pay artificial limbs (prostheses) up to a limit of R55 500. This does not add up to the annual external medical items limit for day-to-day claims.
Certain allied and therapeutic healthcare services are unlimited on the Executive, Comprehensive and Priority Plans
These allied and therapeutic healthcare services are unlimited for the remainder of the year of the trauma event and in the following year:
| • Biokinetics | • Physiotherapists |
| • Acousticians | • Psychologists |
| • Occupational therapists | • Speech and hearing therapists |
Certain allied and therapeutic healthcare services have a specific sub-limit on the Executive, Comprehensive and Priority Plans
These allied and therapeutic healthcare services are covered up to the annual Allied and Therapeutic Benefit limit on your plan:
| • Chiropractors | • Psychometrists |
| • Dietitians | • Registered counsellors |
| • Homeopaths | • Registered nurses |
| • Podiatrists | • Social workers |
Certain sub-limits apply for the Saver and KeyCare Plus Plans as there are no limits on day-to-day cover
Because the Saver and KeyCare Plus Plans do not ordinarily have limits on the available day-to-day cover, we have created certain sub-limits on these plans specifically for the cover available through the Trauma Recovery Extender Benefit.
| Benefit | Limit | |
| Allied and therapeutic healthcare services
Biokineticists Chiropractors Counsellors Dietitians Acousticians Homeopaths Occupational therapists Physiotherapists Podiatrists Psychologists Psychometrists Registered nurses Social workers Speech and hearing therapists | Single member: With one dependant: With two dependants: With three or more dependants: | R4 000 R6 000 R7 500 R9 000 |
| Prescribed medicine, schedule 3 and above | Single member: With one dependant: With two dependants: With three or more dependants: | R4 000 R6 000 R7 500 R9 000 |
| Medical devices (wheelchairs, crutches, etc) | Annual limit of R20 500 for the family | |
| Limb prostheses (artificial limbs) | Annual limit of R55 000 for the family | |
| Hearing aids | Annual limit of R9 600 for the family | |
There are certain healthcare services that are not covered on the Trauma Recovery Extender Benefit
- The Trauma Recovery Extender Benefit does not cover the cost of dentistry, optometry, antenatal classes or over-the-counter (schedule 0, 1 and 2) medicine.
- The general scheme exclusions apply to the Trauma Recovery Extender Benefit.
- The Trauma Recovery Extender Benefit only covers medical claims that are related to the trauma.
About how we pay accounts from the Trauma Recovery Extender Benefit
- The Trauma Recovery Extender Benefit provides cover up to the Discovery Health Rate, except on the Executive Plan where we pay specialists up to 300% of the Discovery Health Rate.
- The co-payment for MRI or CT scans that normally applies will not apply to scans that form part of treatment covered from the Trauma Recovery Extender Benefit.
- We will pay prescribed medicine (schedule 3 and above) from the benefit according to the member’s plan. We will pay generic medicine up to 100% of the Discovery Health Medicine Rate and non-generic medicine will be paid up to 75% of the Discovery Health Medicine Rate on all plans except the Executive Plan, where we pay up to 90% of the Discovery Health Medicine Rate.
