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Discovery Health Classic Smart 2018

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Type of Medical Aid Plan: 
Hybrid
Medical Aid Year: 
2018
Day to day Benefits: 

Unlimited Smart network GP consultations, with a R50 payment for each consultation.

One eye test at a network optometrist with a R50 payment for the test. Covered up to 100% of the Discovery Health Rate (DHR).

One defined dental check-up at any dentist with a R100 payment for the check-up. Covered up to 100% of the Discovery Health Rate (DHR).

Cover for defined acute medicine categories when prescribed by your network GP, with a R10 payment for each medicine item.

Cover for over-the-counter (OTC) medicine obtained from a network pharmacy, up to an annual limit of R600 per family per year.

 

Cover for sports-related injuries:

basic X-rays, two specialist visits and a total of four visits to either a physiotherapist, biokineticist or chiropractor when referred by a Smart Network GP.

You will have to pay R100 for each X-ray or for each visit.

We will cover up to 100% of the Discovery Health Rate (DHR) for these visits and specialists who we don’t have a payment arrangement with.

In Hospital Benefits
Are you prepared to use designated hospitals?: 
Yes
Hospital Rate of Payment: 
Unlimited private hospital cover in the Smart Hospital Network.
Hospitals: 

Unlimited private hospital cover in the Smart Hospital Network.

Specialists we have a payment arrangement with, Full cover.

Specialists we don’t have a payment arrangement with and other healthcare professionals, 200% of the Discovery Health Rate (DHR).

 

Upfront Payments to hospitals: 

For planned admissions at hospitals outside of the Smart Hospital Network, you must pay an upfront payment of R8 800 to the hospital.

Scopes (gastroscopy, colonoscopy, sigmoidoscopy and proctoscopy) You must pay the first R4 200 of the hospital account. The balance of the hospital account and related accounts will be paid from the Hospital Benefit.

MRI and CT scans:

- If related to your admission, we cover your scan up to 100% of the DHR from the Hospital Benefit. 

- If not related to your admission or if for conservative back and neck treatment, you will have to pay the first R2 750 and the balance will be paid from the Hospital Benefit.

The Severe Dental and Oral Surgery Benefit covers a defined list of procedures, with no upfront payment and no overall limit. This benefit is subject to authorisation and the Scheme’s rules.

Other dental treatment in hospital, You need to pay a portion of your hospital or day clinic account upfront for dental admissions.

Hospital, Younger than 13 - R2 200, 13 and older - R5 650.

Day clinic, Younger than 13 - R1 000, 13 and older - R3 650.

We pay the balance of the hospital account from your Hospital Benefit, up to 100% of the DHR. We pay the related accounts, which include the dental surgeon’s account, from your Hospital Benefit, up to 100% of the DHR. We pay anaesthetists up to 200% of the DHR.

 

Casualty / Emergency Visits: 
We cover you in hospital for emergency hospital admissions.
Specialists: 
Specialists we have a payment arrangement with, Full cover. Specialists we don’t have a payment arrangement, 200% of the Discovery Health Rate (DHR).
Other healthcare professionals eg. Physio, Occupational, Dietician: 
Other healthcare professionals, 200% of the Discovery Health Rate (DHR).
Radiology and pathology: 
100% of the Discovery Health Rate (DHR).
Scopes (gastroscopy, colonoscopy, sigmoidoscopy and proctoscopy): 
Scopes (gastroscopy, colonoscopy, sigmoidoscopy and proctoscopy) You must pay the first R4 200 of the hospital account. The balance of the hospital account and related accounts will be paid from the Hospital Benefit.
MRI and CT scans: 
If related to your admission, 100% of the DHR from the Hospital Benefit, if not, , you will have to pay the first R2 750 and the balance will be paid from the Hospital Benefit.
Dialysis: 
We cover these expenses in full if we have approved your treatment plan and you use a provider in our network. If you go elsewhere, we will pay up to 80% of the DHR.
Oncology / Cancer: 
We cover the first R200 000 of the approved cancer treatment in full, over a 12-month cycle. You will be required to pay 20% of the cost on all further treatment once costs for cancer treatment go over R200 000. Prescribed Minimum Benefits are covered in
Joint Replacements: 
We cover planned hip and knee joint replacements in full when you use a provider in our network. If you go elsewhere, we will pay up to 80% of the DHR for the hospital account.
Prosthesis: 

Shoulder joint prostheses, There is no overall limit if you get your prosthesis from our preferred suppliers. If you choose not to, a limit of R40 000 applies to each prosthesis.

Major joints surgery, A limit of R30 000 applies to each prosthesis for each admission. This network will not apply to emergency and trauma-related,surgeries.

Spinal surgery, There is no overall limit if you get your prosthesis from our preferred suppliers. If you choose not to, a limit of R25 500 for the first level and R51 000 for two  or more levels, limited to one procedure for each person each year.

 

In Hospital Dentistry: 
The Severe Dental & Oral Surgery Benefit covers a defined list of procedures, with no upfront payment and no overall limit. Subject to authorisation & the Scheme’s rules. Other dental treatment, a portion of your account upfront for dental admissions.
Treatment for Mental Health: 
21 days for admissions / 15 out-of-hospital consultations for each person for major affective disorders, anorexia and bulimia. 12 out-of-hospital consultations for acute stress disorder. 21 days for all other mental health admissions.
International Travel Benefit: 
Cover for medical emergencies when travelling.
Day-to-day benefits
GP consultations: 

You get unlimited GP consultations when visiting a GP in the Smart GP Network.

You will pay R50 on Classicof the consultation fee with the balance of this fee covered up to the Discovery Health Rate (DHR).

Virtual consultations with your Smart GP are covered in full up to the DHR.

Acute medicine: 

You get cover for certain acute medicine with a R10 payment for each medicine item.

This is limited to 12 prescriptions for each person each year for the defined acute medicine categories.

You need to get your medicine from a network pharmacy.

The categories of medicine we cover can be found on www.discovery.co.za
 

Over-the-counter (OTC) Medicine: 

You get cover for over-the counter (OTC) medicines obtained from a network pharmacy, up to a limit of R600, per family per year.

The categories of medicine we cover can be found on www.discovery.co.za

Optometry benefits: 
You can go for one eye test at an optometrist in the Smart Optometry Network, with a payment of R50.
Basic dentistry: 
You can go for one defined dental check-up at any dentist, with a payment of R100 with the balance of this fee covered up to the DHR.
Specialised Dentistry: 
For members 13 and older, you must pay for routine conservative dentistry, such as preventive treatment, simple fillings and root canal treatment.
Orthodontics: 

There is no overall dental limit. However, you must pay for the cost of all dental appliances, their placements and orthodontic treatment (including the related accounts for orthognathic surgery).

MRI and CT Scans (Out of Hospital): 
On Classic, you must pay the first R2 750 of MRI or CT scan. We cover the balance of the scan from your Hospital Benefit, up to the DHR. For conservative back and neck scans, specific rules and limits may apply.
Pregnancy benefits: 
8 consultations at gynaecologist, Smart network GP or midwife. 1 nuchal translucency/NIPT screening. 2 2D scans. 3D/4D scans at 2D rate. 5 pre- or postnatal classes or consultations. 1 lactation, nutritional assessment & 2 mental healthcare consultations.
Chronic Conditions
Provider: 
Full cover for chronic medicine for all Chronic Disease List conditions on our medicine list when you use MedXpress, Clicks or Dis-Chem.
Chronic Conditions: 

You have cover for the 27 CDL conditions according to the Prescribed Minimum Benefits list. Your condition needs to be approved for it to be covered. Addison’s disease, asthma, bipolar mood disorder, bronchiectasis, cardiac failure, cardiomyopathy, chronic obstructive pulmonary disease, chronic renal disease, coronary artery disease, Crohn’s disease, diabetes insipidus, diabetes Type 1, diabetes Type 2, dysrhythmia, epilepsy, glaucoma, haemophilia, HIV, hyperlipidaemia, hypertension, hypothyroidism, multiple sclerosis, Parkinson’s disease, rheumatoid arthritis, schizophrenia, systemic lupus erythematosus, ulcerative colitis

Total Contributions
Total Contribution Main Member: 
1647.00
Total Contribution Adult: 
1298.00
Total Contribution Child*: 
658.00
Classic Smart
Risk Contributions
Risk Contribution Main Member: 
1647.00
Risk Contribution Adult: 
1298.00
Risk Contribution Child: 
658.00
How many times per annum do you and your dependants visit a doctor?: 
20
How much do you spend on Acute medication per annum?: 
R1000 - R4999
How much do you spend on Chronic medication per annum?: 
R1000 - R4999
Will you or any of your dependants require specialised Dentistry: 
No