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 Smart Hospital Network there will be an upfront payment of R9 650
Casualty / Emergency Visits:
Specialists:
Full cover for specialists we have a payment arrangement with. Other specialists at 200% of DHR
Other healthcare professionals eg. Physio, Occupational, Dietician:
Scopes (gastroscopy, colonoscopy, sigmoidoscopy and proctoscopy):
You pay the first R4 100 of the hospital account. If both a gastroscopy and colonoscopy are performed in the same admission amount rises to R5 150. No upfront payment in dr'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, you pay the first R3 040 of the scan
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 R300 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
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 our network
Medical and Surgical Appliances:
Available from ATB only - R58 800 pfpa
Maternity Confinements:
Subject to pre-authorisation. Unlimited at 100% of DHR. Cover up to R2 150 per day in a private ward for your hospital stay for the delivery
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
