Are you prepared to use designated hospitals?:
Hospital Rate of Payment:
Unlimited at 100% of Discovery Health Rate (DHR)
Upfront Payments to hospitals:
If you use a hospital outside of the Smart Hospital Network there will be an upfront payment of R9 650. Admissions to a facility outside of the Smart Day Surgery Network results in an upfront payment of R9 650
Casualty / Emergency Visits:
Specialists:
Full cover for specialists we have a payment arrangement with. Other specialists at 200% of DHR
Other healthcare professionals eg. Physio, Occupational, Dietician:
Scopes (gastroscopy, colonoscopy, sigmoidoscopy and proctoscopy):
You pay the first R5 000 of the account if done in a day surgery. If both a gastro-and colonoscopy are performed in the same admission amount rises to R6 250. Outside of the day surgery an upfront payment of R9 650 applies No upfront payment in dr'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, you pay the first R3 040 of the scan
Dialysis:
Covered in full if treatment is approved and you use a network provider. If a non-network provider is used Discovery pays up to 80% of the 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:
Cover for the first R200 000 of your approved cancer treatment over a 12-month cycle, in full at 100% of DHR. If your treatment costs more than the cover amount, you pay 20% of the additional costs
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 overall limit if you use a provider in our 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:
21 days of rehabilitation per person per annum. 3 days per approved admission per person for detoxification
Treatment for Mental Health:
Covered in full at a network facility, or up to 80% of DHR at non-network facilities. Protocols apply. Up to 21 days for admissions or up to 15 out-of-hospital consultations pp
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
