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Essential Smart 2021

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

Cover for unlimited Smart Network GP consultations, over-the-counter (OTC) medicine, eye and dental check-ups with fixed co-payments and/or limits

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

Smart Hospital Network. A defined list of procedures are covered in a Smart Day Surgery Network facility

Upfront Payments to hospitals: 

If you use a hospital outside of the Smart Hospital Network there will be an upfront payment of R9 950. Admissions to a facility outside of the Smart Day Surgery Network results in an upfront payment of R9 950

Casualty / Emergency Visits: 
No benefit
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 gastro-and colonoscopy in the same admission amount rises to R4 450. Outside of day surgery upfront payment of R6 250 applies, for both R7 800. No upfront payment in dr's rooms
MRI and CT scans: 
100% of DHR, if done as part of an approved admission. No benefit if not related to your admission. or for conservative back and neck treatment
ICU and High Care: 
Unlimited at 100% of DHR
Dialysis: 
Covered at a provider in a state facility
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. Covered in the Discovery network
Neck and Back Operations: 
No benefit
Joint Replacements: 
Limited to arthroscopies only
Prosthesis: 

Cochlear implants, auditory brain implants and processors; R230 400 per beneficiary, per benefit: Internal nerve stimulators: no cover; 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 200 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: 
Cover for Severe Dental & Oral Surgery for a defined list of procedures only
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: 

Unlimited at a GP in the Smart Network. You pay R110 of the consultation fee with the balance of the fee covered at 100% of DHR. Video consultations with your Smart Network GP are covered in full up to DHR

Specialist consultations: 

2 specialist visits when related to a sport injury and referred by your Smart Network GP. You pay R110 for each visit and Discovery will cover the rest up to DHR

Acute medicine: 

No benefit

Over-the-counter (OTC) Medicine: 

Limited to R475 pfpa from Clicks or Dis-Chem pharmacies

Optometry benefits: 
Cover for one eye test per year at a network optometrist, with an upfront payment of R110. Covered up to 100% of DHR
Basic dentistry: 
One defined dental check-up per year at any dentist, dental therapist or oral hygienist, with an upfront payment of R165. The balance is covered up to 100% of DHR
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, Clicks or Dis-Chem
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: 
1400.00
Total Contribution Adult: 
1400.00
Total Contribution Child*: 
1400.00
Essential
Risk Contributions
Risk Contribution Main Member: 
1400.00
Risk Contribution Adult: 
1400.00
Risk Contribution Child: 
1400.00
Medical Aid Plan Name Term: 
Essential Smart