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Coastal Core 2021

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Type of Medical Aid Plan: 
Hospital
Medical Aid Year: 
2021
Day to day Benefits: 

No benefit

In Hospital Benefits
Are you prepared to use designated hospitals?: 
Yes
Hospital Rate of Payment: 
Unlimited at 100% of Discovery Health Rate (DHR)
Hospitals: 

Any private hospital in the four coastal provinces approved by Discovery Health. A defined list of procedures are covered in a Coastal Day Surgery Network facility

Upfront Payments to hospitals: 

If you use a hospital outside of the Coastal Network, Discovery pays 70% of the DHR and you are responsible for the other 30%.  Admissions to a facility outside of the Day Surgery Network, where applicable, results in a R5 700 upfront payment

Casualty / Emergency Visits: 
Emergencies are covered in full, if the treatment meets Discovery Health criteria
Specialists: 
Full cover for specialists we have a payment arrangement with. Other specialists at 100% of DHR
Other healthcare professionals eg. Physio, Occupational, Dietician: 
Unlimited at 100% of DHR
Radiology and pathology: 
Unlimited at 100% of DHR
Scopes (gastroscopy, colonoscopy, sigmoidoscopy and proctoscopy): 
You pay the first R3 650 if done in a day surgery. If both a gastro- and colonoscopy done in the same admission the amount rises to R6 250. If done in hospital there is an upfront payment of R8 700 plus a co-pay of R4 450 or R7 800
MRI and CT scans: 
100% of DHR, if done as part of an approved admission. No payment if for conservative back and neck treatment
ICU and High Care: 
Unlimited at 100% of DHR
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: 
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).
Oncology / Cancer: 
Cover for the first R200 000 of your approved cancer treatment over a 12-month cycle in full at 100% of DHR. Cancer treatment that is a PMB is covered in full and adds up to the cover amount. 80% cover for 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. A defined basket of care for conservative spinal treatment
Joint Replacements: 
No overall limit if you use a provider in the network
Prosthesis: 

Cochlear implants, auditory brain implants and processors; R230 400 per beneficiary, per benefit: Internal nerve stimulators; R165 300 per beneficiary: Shoulder Joint; if you use a non-network provider, up to R42 950: Major joint surgery; if you use a non-network provider, 80% of DHR up to a maximum of R30 900 per prosthesis, per admission: Spinal surgery; if you use a non-network provider, limited to R26 250 for 1st level and R52 500 for 2 or more levels

Medical and Surgical Appliances: 
No benefit
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
Take home Medicine: 
No benefit
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
Ambulance Service: 
Netcare 911
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.
Day-to-day benefits
GP consultations: 

No benefit

Specialist consultations: 

No benefit

Acute medicine: 

No benefit

Over-the-counter (OTC) Medicine: 

No benefit

Optometry benefits: 
No benefit
Basic dentistry: 
No benefit
Specialised Dentistry: 
No benefit
Orthodontics: 

No benefit

MRI and CT Scans (Out of Hospital): 
No benefit
Radiology and Pathology: 
No benefit
Pregnancy benefits: 
8 antenatal consultations, 2 x 2D scans, including 1 x nuchal translucency test. A defined basket of blood tests. 5 x antenatal or postnatal classes or consultations with a registered nurse up until 2 years after giving birth
Physiotherapy and Occupational Therapy day to day: 
No benefit
Chronic Conditions
Provider: 
MedXpress or a MedXpress network pharmacy
Chronic Conditions: 

Diagnosis, treatment and care costs of 26 chronic conditions that fall under the PMB Chronic Disease List (CDL), issued by the Council for Medical Schemes. Subject to approval by the Chronic Illness Benefit

Additional Chronic Conditions: 
None
Preventative Care Benefits
Preventative Benefits: 

Screening tests for adults and children at a wellness network provider. Age specific tests for: pap smear, mammogram, prostate and HIV screening tests. Flu vaccine during pregnancy and for members > 65 years. Bowel cancer screening tests for members 45-75 years

Total Contributions
Total Contribution Main Member: 
2062.00
Total Contribution Adult: 
1548.00
Total Contribution Child*: 
820.00
Coastal Core
Risk Contributions
Risk Contribution Main Member: 
2062.00
Risk Contribution Adult: 
1584.00
Risk Contribution Child: 
820.00