To offer your patients the best care and advice, being able to advise them on what is and isn’t covered by their medical schemes is important. That is why we want to work with you to eliminate any possible confusion between the different rates and pricing, as well as the funding rules for the National Pharmaceutical Product Index (NAPPI) codes.
When a member’s needs require the use of external medical items, Discovery Health has three
options to cover the cost:
- They would use funds from their Medical Savings Account (MSA)
- Use the Above Threshold Benefit (ATB) if their MSA is depleted
- If a member is outside of both of the above parameters, they will have no funds available or, if the plan that they belong to provides for it, they will fall into the Self-Payment Gap (SPG). In both instances, they would need to cover the medical items out of their own pocket.
Discovery Health will pay for a product, provided that the associated account reflects a valid NAPPI code with a valid listed price.
Please use the link below to determine the MediKredit listed price for NAPPI coded items.
Importantly, suppliers are responsible for updating their listed prices regularly with both Medikredit and with Discovery Health. If there are issues that arise out of incorrectly listed prices Discovery will make every attempt to contact the supplier to obtain the most updated list. Members are also welcome to contact SAOPA for assistance.
DISCOVERY HEALTH’S FREQUENCY LIMITS
Certain external medical items are further restricted by a frequency limit and will only be paid up to the Discovery Health Rate if annual frequency limit was not reached or exceeded. Practitioners are urged to ensure that patients have benefits available before issuing devices with annual frequency limits. The following categories of external medical items have frequency limits:
- Mobility devices including other specialised appliances for disability
- Breathing devices
- Insulin pumps
- Breast pumps
- Glucose monitoring device
- Blood pressure monitors
- Hoists and motorised lifts
- Apnoea and movement monitors
HOW PRESCRIBED MINIMUM BENEFITS AFFECT THE ADVICE YOU GIVE
Prescribed Minimum Benefits (PMB) are a set of defined benefits to ensure that all medical scheme members have access to certain minimum health services, regardless of the benefit option they have selected.
As is often the case, plan benefits go above and beyond the PMB funding, broadening the scope of external medical items that can be offered. Orthotists and prosthetists must discuss all treatment options with their patients to find the product that suits them best – meeting their needs both physically and financially.
While standard products available through preferred suppliers are always guaranteed to be fully covered, co-payments may apply when other products are selected, or non-preferred suppliers are involved. Therefore, the mere fact that a patient has a Prescribed Minimum Benefit condition does not provide a guarantee for all services provided and/or expenses incurred.
REGARDING THE PREFERRED SUPPLIER FOR PROSTHETIC COMPONENTS
Discovery is in the process of negotiating with preferred suppliers for prosthetic components. This means that going forward Discovery will only reimburse at the lower of the charged rate and the rates negotiated for these components. If other (more expensive) components are used and charged for member co-payments will be incurred
This development is likely to have a profound impact on how Prosthetists are used to practising, but the SAOPA Non-executive Committee does not believe that it is necessarily a negative one. However, it re-emphasises the importance of claiming for professional services provided and components used. The professional services codes that are in use currently can be accessed below.
Discovery was planning to go live with this initiative on 1st July 2020 but during a recent meeting, SAOPA managed to negotiate a postponement on this date so that members can be properly informed and prepared. Please be on the lookout for further communication on this matter.
Thank you for the support!