Are you prepared to use designated hospitals?:
Hospital Rate of Payment:
We pay for planned hospital stays from your Hospital Benefit. We pay for servicesrelated to your hospital stay, includingall healthcare professionals, services,medicines authorised by the Schemefor your hospital stay.
Upfront Payments to hospitals:
Upfront payment for a defined list of procedures performed outside
of the day surgery network : you must pay an upfront payment of R6 250
Casualty / Emergency Visits:
We pay for all the following medical services you may receive in emergency:the ambulance (or other medical transport) account from the hospital, accounts from doctor who admitted you to the hospital, anaesthetist any other h...
Specialists:
Specialists we have a payment arrangement with The full account at the agreed rateSpecialists we don’t have a payment arrangement with and otherhealthcare professionalsUp to twice the Discovery Health Rate (200%)
Other healthcare professionals eg. Physio, Occupational, Dietician:
Up to twice the Discovery Health Rate (200%)
Radiology and pathology:
The Discovery Health Rate (100%)
Scopes (gastroscopy, colonoscopy, sigmoidoscopy and proctoscopy):
The first R6 250 of the hospital account is paid from your available MSA. If both a colonoscopy and gastroscopy are performed in the same admission the amount increases to R6 250. No upfront payment if done in doctor's rooms
MRI and CT scans:
100% of DHR, if done as part of an approved admission. If not related to your admission. or for conservative back and neck treatment, the first R3 130 of the scan is paid from available MSA
ICU and High Care:
Prescribed Minimum Benefit (PMB) conditions in terms ofthe Medical Schemes Act 131 of 1998 and its Regulations,all medical schemes have to cover the costs related to thediagnosis, treatment and care of:An emergency medical conditionA defined lis...
Dialysis:
We cover these expenses in full if we have approvedyour treatment plan and you use a provider in ournetwork. If you go elsewhere, we will pay up to 80%of the Discovery Health Rate (DHR).
Organ Transplants:
Cover for transplant surgery explained on authorisation request. Discovery pay for appropriate, approved work-up costs for recipient, procurement of organ and necessary tests done on donor before harvesting organ, even if donor is not a member of DH
Oncology / Cancer:
If you are diagnosed with cancerand once we have approved yourcancer treatment, you are coveredby the Oncology Care Programme.We cover your approved cancertreatment over a 12-month cycle.We cover the first R200 000. If yourtreatment costs more...
Neck and Back Operations:
No overall limit if you get your prosthesis from a preferred supplier. Limited to 1 procedure per beneficiary per annum
Joint Replacements:
No limit for planned hip and knee joint replacementsif you use a provider in our network.80% of the Discovery Health Rate (DHR) if you use a provideroutside our network up to a maximum of R30 900 for eachprosthesis for each admission.The network...
Medical and Surgical Appliances:
Maternity Confinements:
Subject to pre-authorisation. Unlimited at 100% of DHR
In Hospital Dentistry:
Upfront payments for dental admissions, dependant on age and place of treatment. Balance of hospital and related accounts are paid from hospital benefit at 100% of DHR. Severe Dental & Oral Surgery has a separate benefit for a defined list of procedures
Rehabilitation, Hospice and Step-down facilities:
We pay for 21 days of rehabilitation per personeach year. Three days per approved admission per personfor detoxification."We pay for 21 days of rehabilitation per personeach year. Three days per approved admission per personfor detoxification."
Treatment for Mental Health:
21 days for admissions or up to 15 out-of-hospitalconsultations per person for major affective disorders. All mental health admissions are covered in full at a networkfacility. If you go elsewhere, we will pay up to 80% of theDiscovery Health Rate...
HIV / AIDS:
Subject to registration on the HIV programme. Choose a Premier Plus HIV Network GP and Specialist to manage your condition to avoid a 20% co-payment
International Travel Benefit:
Cover up to R5 million per person, per journey, for a period of 90 days, for emergency medical costs while travelling outside of SA
