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DISCOVERY HEALTH ESSENTIAL PRIORITY 2019

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

15% of your monthly contribution goes into your Medical Savings Account (MSA)

In Hospital Benefits
Hospital Rate of Payment: 
Covered in full at the rate agreed with the hospital
Hospitals: 

any private hospital

Upfront Payments to hospitals: 

-Conservative back and neck treatment, adenoidectomy, myringotomy (grommets), tonsillectomy R3 350

-Colonoscopy, sigmoidoscopy, proctoscopy, gastroscopy, cystoscopy R4 250

-Arthroscopy, functional nasal procedures, hysterectomy (except for pre-operatively diagnosed cancer), laparoscopy, hysteroscopy, endometrial ablation R7 950

-Nissen fundoplication (reflux surgery), spinal surgery (back and neck), joint replacementsR16 350

If the procedure can be done out of hospital, for example in the doctor’s rooms, you won’t have to pay an amount upfront to the hospital. If any of these procedures form part of the defined list of procedures, the higher of the upfront amounts payable will be applicable if performed outside of the day surgery network.

 

-MRI and CT scans If related to your admission, we pay 100% of the DHR from the Hospital Benefit. If not related to your admission or for conservative back and neck treatment, you have to pay the first R3 350 of the hospital account and we pay the first R2 900 of the scan from your day-to-day benefits. We pay the balance of the scan from the Hospital Benefit, up to 100% of the DHR.

Specialists: 
Specialists we have a payment arrangement with Full cover Specialists we don’t have a payment arrangement with and other healthcare professionals 100% of the Discovery Health Rate (DHR)
Radiology and pathology: 
100% of the Discovery Health Rate (DHR)
Scopes (gastroscopy, colonoscopy, sigmoidoscopy and proctoscopy): 
You must pay R4 250 upfront, we pay the balance of hospital account and related accounts from the Hospital Benefit. If done in the doctor’s rooms, we pay the account from your Hospital Benefit.
MRI and CT scans: 
If done as part of an approved admission, we pay up to 100% of DHR from the Hospital Benefit. If not related to your admission, we pay the first R2900 from your daytoday benefits. We pay the balance of the scan from the Hospital Benefit up to 100% of DHR.
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).
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.
Joint Replacements: 
We cover planned hip and knee joint replacements in full when you use a provider in our network.
Prosthesis: 

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.

Maternity Confinements: 
100 % of Discovery Health Rate.
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.
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: 

100% of the DHR

Specialist consultations: 

Specialists we have a payment arrangement with Up to the agreed rate
Specialists we don’t have a payment arrangement with 100% of the DHR

Over-the-counter (OTC) Medicine: 

We pay these claims from the available funds in your Medical Savings Account (MSA). These claims do not add up to the Annual Threshold and are not paid from the limited Above Threshold Benefit (ATB).

Optometry benefits: 
R5 000 for each person
Basic dentistry: 
There is no overall limit for basic dental treatment. However, all dental appliances, their placement, and orthodontic treatment (including related accounts for orthognathic surgery) are paid at 100% of the Discovery Health Rate (DHR)
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.
Chronic Conditions
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

Total Contributions
Total Contribution Main Member: 
3010.00
Total Contribution Adult: 
2365.00
Total Contribution Child*: 
1202.00
Essential Priority
Annual Medical Savings Account
Annual Medical Savings Main Member: 
5412.00
Annual Medical Savings Adult: 
4248.00
Annual Medical Savings Child*: 
2160.00
Monthly Medical Savings
Savings Child*: 
180.00
Savings Adult: 
354.00
Savings Main Member: 
451.00
Annual Threshold Amounts
Annual Threshold Main Member: 
15800.00
Annual Threshold Adult: 
11800.00
Annual Threshold Child*: 
5200.00
Above Threshold Benefit Limits
Above Threshold Benefit Main Member: 
13400.00
Above Threshold Benefit Adult: 
9550.00
Above Threshold Benefit Child*: 
4600.00
Risk Contributions
Risk Contribution Main Member: 
2559.00
Risk Contribution Adult: 
2011.00
Risk Contribution Child: 
1022.00
Medical Aid Plan Name Term: 
Any