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 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 500 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:
Scopes (gastroscopy, colonoscopy, sigmoidoscopy and proctoscopy):
The first R5 000 of the hospital account is paid from your available MSA. If both a colonoscopy and gastroscopy are performed in the same admission the amount increases to R6 250. No upfront payment if done in doctor'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, the first R3 040 of the scan is paid from available MSA
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. 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
Joint Replacements:
No overall limit if you use a provider in the 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
