By now you are probably aware that IFAASA has been in discussions with Discovery Health Medical Scheme (DHMS) regarding the coverage offered for the diagnosis and treatment of infertility. Please note that you need to ensure you know what you are entitled to in terms of cover for infertility, neither your healthcare professional, nor the representatives you deal with at Discovery Health will necessarily know the below…
In a previous meeting with DHMS, it was agreed that a claims process needs to be documented and communicated to members.
The process is explained below. Should you have any further questions in this regard, please let us know at saskia@ifaasa.co.za. If we are not able to answer your question, we will get clarity from DHMS.
PMB Claims process:
With regards to out of hospital tests and procedures as listed below in Annexure A of the Medical Schemes Act:
a) hysterosalpingogram
b) the following blood tests:
i) Day 3 FSH/LH
ii) Oestradiol
iii) Thyroid function (TSH)
iv) Prolactin
v) Rubella
vi) HIV
vii) VDRL
viii) Chlamydia
ix) Day 21 Progesterone
c) laparoscopy
d) hysteroscopy
e) surgery (uterus and tubal)
f) manipulation of ovulation defects and deficiencies
h) semen analysis (volume; count; mobility; morphology; MAR-test)
j) basic counselling and advice on sexual behaviour, temperature charts etc.
k) treatment of local infections.
DHMS will initially deduct the out of hospital claims from the member’s medical savings account until a definitive infertility diagnosis is made. Once the diagnosis is made it is the member’s responsibility to complete the DHMS form ‘Application for out-of-hospital management of a Prescribed Minimum Benefit condition’ and ensure the treating physician completes the relevant parts. Once DHMS has received this form from the member and processed it, the claims for the above procedures will be reimbursed to your savings account. If your Medical Savings account is depleted of funds you are required to pay for the diagnostic tests yourself and once the application form has been completed DHMS will reimburse the member directly.
If you have any problems with the process, please contact the DHMS Call Centre on 0860 99 88 77 or email: healthinfo@discovery.co.za
Discovery Health Medical Scheme (DHMS) claims process for members wanting to use their medical savings account funds to cover treatment that fall outside of the PMBs and which are not covered by the Scheme (namely Fertility treatment)
If the member has been with the Scheme for more than a year, the member is able to access the full balance in their MSA and use it for funding of their fertility treatment. There has to be available funds within the Medical Savings Account, this application does not apply to the Above Threshold Benefit.
Members have to complete the form Application for special payments from the Medical Savings Account 2020 and submit the form to DHMS.
If you have any problems with the process, please contact the DHMS Call Centre on 0860 99 88 77 or email: healthinfo@discovery.co.za
My partner and myself have decided we are ready to try for a child, we are both on different discovery plans, at a young age a injury accrued with him and since then he has been told his sperm count is extremely low. if it should come to looking at other avenues of trying to conceive such as insemination. is something like that covered by my Discovery Coastal. I have been with Discovery for about 4 years or longer. also to add I am 31 years old and already have a 6yr old. I just need to know if I must also get tested, what is the procedure
Hi There
Diagnosis of infertility is covered by Discovery on any plan, as it is a prescribed minimum benefit disease but, no treatment is covered. I would suggest that you both get tested to ensure that all bases are covered. Your first step would be to find a fertility specialist near you, make an initial appointment and then go from there. You will need to pay for everything upfront though and then claim through discovery. The specialists appointment will probably not be covered fully, depending on where you go. Go to http://www.sasreg.co.za for a list of clinics nationwide.
I am with Discovery Essential Saver. I had cancer, no uterus.
There are still eggs of mine that can be harvested.
Eggs will be frozen and through IVF and sperm donor will be put into a surrogate mother.
Which of these costs will Discovery be able to help me with?
Hi Elizma
Please contact Discovery re what they will cover, I am sorry you find yourself in this situation.
I want to reopen my tubes I was sterilise wil discovery keycard plus cover for the reopening
Hi Bibi. No, unfortunately they won’t pay for that.
Hi
Will other medical aids namely GEMS also follow discovery decision ?
I’m turning 40 at the end of this year. I have two children already but I have a new partner and we would love to have a child. I had tubal surgery after my last born 8yrs ago. Will discovery cover for the tubal reversal. I am on a coastal saver plan.
Please contact Discovery or your Broker for that information.
Dear IFAASA,
Is it not true that if 3 different government institutions offer a treatment/procedure then the private medical schemes HAVE TO fund same at the minimum PMB rate?
“Groote Schuur, Tygerburg and Steve Biko hospitals have full IVF facilities and the patient only has to pay for their medication.”
We have so many YOUNG ladies being diagnosed with breast cancer that require chemotherapy – they are requiring Fertility treatment too and of course majority of patients are on Discovery… I find it unethical that such is not funded by the schemes. Cancer is not a choice.
I would love to be a part of and assist you guys however you need!
Warmly,
Kyrie
Hi Kyrie. You are right and, that’s exactly the fight we are going to have when we have raised the funds to engage our legal team who think we have a very good chance. Please have a look at and share the link: https://www.backabuddy.co.za/champion/project/ifaasa-campaign
It is even more awful that they do not cover oncofertility for the patients that you mention.
You are welcome to email me on saskia@ifaasa.co.za to carry on this conversation.
Many thanks, Saskia