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DISCOVERY HEALTH ESSENTIAL SAVER 2019

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Type of Medical Aid Plan: 
New Generation
Medical Aid Year: 
2019
Day to day Benefits: 

15% of your monthly contribution goes into your Medical Savings Account (MSA). We pay for day-to-day medical expenses like visits to healthcare professionals, radiology and pathology from your MSA, as long as you have money available. We cover your face-to-face and video GP consultations if you use a GP in our network on HealthID who meets the digital criteria, up to: Single member 2 consultations and Family 4 consultations

Co-payments: 
Scopes (gastroscopy, colonoscopy, sigmoidoscopy and proctoscopy) R4 550. Dental admissions in hospital younger than 13 - R2 400, 13 and older - R6 200 Day clinic Younger than 13 - R1 100, 13 and older - R4 000, MRI & CT Scans in or out of hospital R2 900
In Hospital Benefits
Hospital Rate of Payment: 
100% of Scheme Rate.
Hospitals: 

Any private hospital

Upfront Payments to hospitals: 

Scopes (gastroscopy, colonoscopy, sigmoidoscopy and proctoscopy) R4 550.

Dental admissions in hospital Younger than 13 - R2 400 13 and older - R6 200 Day clinic Younger than 13 - R1 100 13 and older - R4 000

MRI & CT Scans in or out of hospital R2 900

Casualty / Emergency Visits: 
Subject to savings.
Specialists: 
In our network, full cover. Not in our network 100% of the Discovery Health Rate.
Other healthcare professionals eg. Physio, Occupational, Dietician: 
In our network, full cover. Not in our network 100% of the Discovery Health Rate.
Radiology and pathology: 
100% of the Discovery Health Rate (DHR)
Scopes (gastroscopy, colonoscopy, sigmoidoscopy and proctoscopy): 
We pay the first R4 550 of the hospital account from your day-to-day benefits and the balance of the hospital account and related accounts from the Hospital Benefit. If done in the doctor’s rooms, you won’t have to pay an amount upfront.
MRI and CT scans: 
If related to your admission, we pay up to 100% of the DHR from the Hospital Benefit. If not related to your admission or if for conservative back and neck treatment, we pay the first R2 900 of the scan from your day-to-day benefits
ICU and High Care: 
100 % of Discovery Health Rate.
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 Discovery Health Rate (DHR).
Organ Transplants: 
As per Scheme Protocols.
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 fully covered.
Neck and Back Operations: 
There is no overall limit if you get your prosthesis from our preferred suppliers. If you choose not to, a limit of R25 000 for the first level and R51 000 for two or more levels, limited to one procedure for each person each year.
Joint Replacements: 
There is no overall limit if you get your prosthesis from our preferred suppliers. If you choose not to, certain limits may apply to each prosthesis.
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 R41 700 applies to each prosthesis.

Major joints surgery 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. A limit of R30 000 applies to each prosthesis for each admission.

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 applies for the first level and R51 000 for two or more levels, limited to one procedure for each person each year.

Medical and Surgical Appliances: 
Subject to savings.
Maternity Confinements: 
100 % of Discovery Health Rate.
In Hospital Dentistry: 
Upfront payment. Balance of hospital account, dental surgeon & related accounts 100% of the DHR. Dental appliances & orthodontic treatment incl related accounts for orthognathic surgery we pay from your savings if you have money available.
Take home Medicine: 
If collected before discharge from hospital from hospital benefit. If collected after discharge from hospital, from savings account.
Rehabilitation, Hospice and Step-down facilities: 
21 days for each person.
Treatment for Mental Health: 
21 days for admissions or up to 15 out-of-hospital consultations for each person for major affective disorders, anorexia and bulimia, and up to 12 out-of-hospital consultations for acute stress disorder accompanied by recent significant trauma.
HIV / AIDS: 
When you register for our HIVCare Programme, you are covered for the care you need, which includes additional cover for social workers. Be assured of confidentiality at all times. You need to get your medicine from a DSP to avoid a 20 % co-payment.
Ambulance Service: 
Netcare 911
International Travel Benefit: 
Cover up to R5 million for each person on each journey for emergency medical costs while travelling outside of South Africa, for a period of 90 days from your departure from South Africa. Specific rules apply and pre-existing conditions are excluded.
Day-to-day benefits
GP consultations: 

Subject to savings.

Specialist consultations: 

Subject to savings.

Acute medicine: 

Subject to savings.

Over-the-counter (OTC) Medicine: 

Subject to savings.

Optometry benefits: 
Subject to savings. Enjoy savings of 20% for frames and lenses at an optometrist in the network. Your discount is immediate at the point of sale.
Basic dentistry: 
Subject to savings.
Specialised Dentistry: 
Subject to savings.
Orthodontics: 

Subject to savings.

MRI and CT Scans (Out of Hospital): 
We pay the first R2 900 of the scan from your savings. We pay the balance of the scan from the Hospital Benefit, up to 100% of the Discovery Health Rate.
Radiology and Pathology: 
Subject to savings.
Pregnancy benefits: 
You are covered for 8 consults at your gynaecologist, GP or midwife. 1 NIPT screening, 2x 2D ultrasound scans, a defined basket of blood tests, 1 flu vaccination, 5 pre- or postnatal classes or consults with a registered nurse. Paid from Hospital Benefit.
Physiotherapy and Occupational Therapy day to day: 
Subject to savings.
Chronic Conditions
Provider: 
Designated Service Provider.
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.

Chronic Disease List: 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.

Additional Chronic Conditions: 
No Benefit.
Preventative Care Benefits
Preventative Benefits: 

Covers certain tests at one of our wellness network providers; blood glucose, blood pressure, cholesterol and body mass index. We also cover a mammogram every 2 years >35 years, Pap smear every 3 years >16 years, PSA (a prostate screening test) once a year >50 years and HIV screening tests. Seasonal flu vaccine during pregnancy, or for members 65 years or older and/or registered for certain chronic conditions. Additional, and/or more frequent screening is available for those who meet our clinical criteria. Kids screening covers growth assessment and health and milestone tracking at any one of our wellness network providers.

Total Contributions
Total Contribution Main Member: 
2400.00
Total Contribution Adult: 
1800.00
Total Contribution Child*: 
962.00
Essential Saver
Annual Medical Savings Account
Annual Medical Savings Main Member: 
4320.00
Annual Medical Savings Adult: 
3240.00
Annual Medical Savings Child*: 
1728.00
Monthly Medical Savings
Savings Child*: 
144.00
Savings Adult: 
270.00
Savings Main Member: 
360.00
Risk Contributions
Risk Contribution Main Member: 
2040.00
Risk Contribution Adult: 
1530.00
Risk Contribution Child: 
818.00