Discovery Essential Priority medical aid plan: 2019

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Please note that these benefits are still being updated as more information is made available to us. Always consult with your broker before making final decisions regarding your healthcare cover.

Essential Priority
2018 Costs:
Total Cost pm:

Main member:

R2,763

Adult:

R2,172

Child: (Pay only for first 3)

R1,103
Savings Account (yr): R4,968 R3,900 R1,980
Self Payment Gap:
R9,272 R6,770 R2,680
Above Threshold: R12,080 R8,610 R4,170
2019 Costs:
Total Cost pm:

Main member:

R3,010
(8.94%)

Adult:

R2,365

Child: (Pay only for first 3)

R1,202
Savings: R5,412 R4,248 R2,160
Self Payment Gap:
R10,468 R7,632 R3,040
Above Threshold: 17 9,550 4,600
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In brief (2018):
  • Scheme rate is 100%, and most day-to-day expenses are paid by scheme, or from savings, or from threshold benefit.
  • There is a self payment gap before threshold is reached. The threshold is limited.
  • There are co-payments for certain procedures
  • Discovery does pay for most maternity expenses and some preventative benefits such as mammograms and pap smears
  • You get unlimited cancer cover, with a co-payment after R200,000
  • Travel insurance and international treatment
  • Diagnosis and treatment of the 270 PMBs is always paid by scheme, in and out of hospital, according to protocols.
See full benefits below

IN HOSPITAL PROCEDURES:
Essential Priority
Scheme Benefits: Gap Benefits:
Specialists:
  • Up to 100% scheme rate
  • Contracted Specialists: covered in full
  • You or gap cover pay the balance, if any
AskAdam Gap
  • Gap tops up to 500% the scheme rate for in-hospital specialists, GPs and other medical professionals
  • Recommended for this plan: Plan Blue, R295pm per family where no member is older than 64yrs (otherwise, R435pm per family)
Discovery Gap:
  • Up to 300% of scheme rate for specialists only
  • An additional benefit (between R2,500 and R20,000) can pay-in for some out-of-hospital expenses related to admission
  • Starts at R165 (single) and R395(family) for this plan. More Info or contact Discovery below
Hospital Choice:
  • Choose any hospital
  • No benefit, unless PMB
Specialised Radiology:
  • If not related to admission or for conservative back or neck treatment, R3,050 co-payment for the scan, and R2,750 towards the hospital account is paid by you.
AskAdam Gap:
  • Co-payment benefit pays the co-payments
Discovery Gap:
  • No benefit
Supplementary Services: (Physio, etc)
  • Covered in full for professionals with payment arrangement with Discovery
  • Otherwise, 100% scheme rate
AskAdam Gap
  • Gap tops up to 500% the scheme rate for in-hospital specialists, GPs and other medical professionals
Discovery Gap:
  • R2,500-R20,000 for some outstanding costs not covered by scheme
Transplants:
  • Covered
AskAdam Gap
  • Gap tops up to 500% the scheme rate for in-hospital specialists, GPs and other medical professionals
Discovery Gap:
  • 300% of scheme rate for specialists only
  • Additional R2,500-R20,000 for some outstanding costs not covered by scheme
Co-payments:
  • Defined procedures performed outside of day surgery network: R5,000
  • Scopes: R4,250 co-payment
  • Adenoidectomy, myringotomy (grommets), tonsillectomy, conservative back treatment: R3,350 co-payment
  • Arthroscopy, functional nasal procedures, hysterectomy, laparoscopy, hysteroscopy, endometrial ablation: R7,950 co-payment
  • Reflux surgery, spinal surgery, joint replacements: R16,350 co-payment
  • No co-payment if procedure can and is done out-of-hospital
  • In-hospital dentistry: co-payment required for some admissions. See dentistry benefit for details
AskAdam Gap:
  • Co-payment benefit pays the co-payments
Discovery Gap:
  • No benefit, unless PMB
Alternatives to hospitals:
  • Administration of IV, iron treatments, steroids and immunoglobulins when a hospital admission is not required: covered
  • Care for venous ulcers, diabetic foot ulcers, pressure sores and other moderate to severe wounds for patients who do not require hospital admission: covered
  • Terminal care: R62,200 per person, per lifetime
  • Cancer: Unlimited palliative care cover for approved care at home
  • No extra benefit available
Casualty:
  • Accident and trauma (emergency) related costs covered
AskAdam Gap:
  • Pays up to R20,000 per person per year for emergency medical treatment not paid for by medical aid

Discovery Gap:
  • No additional benefit
Other:
  • Cochlear implants: R223,700
  • Internal Nerve stimulators: R153,600
  • N/A
Note:
  • Gap cover is an add-on to your medical aid, not a stand alone product
  • Gap cover has a maximum benefit payout of R150,000 per person per year for all gap benefits (except dread disease and premium waiver benefits which do not count towards the R150,000 limit)
  • Gap only supplements payment for procedures approved or authorised by your medical aid, and does not cover “penalties” (such as if, for example, you choose a non-DSP doctor for your procedure when the plan required a DSP doctor)
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All benefits, including gap benefits, are subject to treatments and procedures being authorised by medical scheme.
The gap benefits listed are for AskAdam gaps, unless otherwise stated. Actual benefits depend on gap choice option.

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OUT OF HOSPITAL BENEFITS (non-PMB):
Essential Priority
Scheme Benefits Gap benefits
Main: Adult: Child:
Savings /yr: R4,968 R3,900 R1,980
Self Payment:
(per year, if you use up all your savings)
R9,272 R6,770 R2,680
Above Threshold: R12,080 R8,610 R4,170
General info: AskAdam
  • Our recommended gap cover does not pay out-of-hospital claims, unless it is for cancer treatment, dialysis, or MRI/CT scans
Discovery Gap:
  • Additional R2,500-R20,000 for some outstanding costs not covered by scheme, related to hospital admissions
GP consultations:
  • From day-to-day benefit unless PMB
  • No benefit, unless PMB
Childcare:
  • No extra benefit available
Specialists consultations:
  • From day-to-day benefit, unless PMB
  • 100% scheme rate unless Discovery has payment arrangement with specialist
AskAdam Gap:
  • No benefit
Discovery Gap:
  • An additional benefit (between R2,500 and R20,000) can pay-in for some out-of-hospital expenses related to admission
Pathology:
  • From day-to-day benefit, unless PMB
AskAdam Gap:
  • No benefit
Discovery Gap:
  • An additional benefit (between R2,500 and R20,000) can pay-in for some out-of-hospital expenses related to admission
General radiology:
  • From day-to-day benefit, unless PMB
AskAdam Gap:
  • No benefit
Discovery Gap:
  • An additional benefit (between R2,500 and R20,000) can pay-in for some out-of-hospital expenses related to admission
Specialised radiology:
  • From day-to-day benefit, unless PMB
  • No benefit, unless PMB
Supplementary Services: (Physio, etc)
  • From day-to-day benefits. Includes allied, therapeutic and psychology services
Main M1 M2 M3+
R7,350 R11,100 R13,800 R16,650
AskAdam Gap:
  • No benefit
Discovery Gap:
  • An additional benefit (between R2,500 and R20,000) can pay-in for some out-of-hospital expenses related to admission
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MATERNITY BENEFITS:
Essential Priority
Scheme Benefits Gap benefits
Hospital stay:
  • 100% scheme rate
AskAdam Gap:
  • Pays up to 500% scheme rate for specialists, GPs and other medical professionals, in-hospital only
Discovery Gap:
  • 400% of scheme rate for specialists only
  • Additional R2,500-R20,000 for specialist costs not fully covered by this
  • Starts at R160 (single) and R395(family). More Info or contact Discovery below
Consultations:
    Discovery pays for:
  • 8 consults, paid by scheme
  • Nuchal translucency or Non-Invasive Prenatal Test, paid by scheme
  • Certain blood tests, paid by scheme
  • Five pre- or postnatal classes with registered nurse
  • One lactation consult
  • No benefit, unless PMB
Scans:
    Discovery pays for:
  • 2 x ultrasound scans
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CANCER (ONCOLOGY):
Essential Priority
Scheme Benefits Gap benefits
Overall coverage (in and out of hospital):
  • Unlimited. After the first R200,000, a 20% co-payment applies for non-PMB cancers
  • All cancer-related treatments are covered at 100% scheme rate
  • Specialised medicine and technology: No benefit, unless PMB
  • Unlimited palliative care cover for approved care at home
AskAdam Gap
  • Once you or the medical scheme have spent R200,000 per oncology treatment cycle from a private hospital, the gap cancer benefit will cover costs authorised but not paid by your medical scheme (up to the R150,000 per person per year gap limit) More info

Discovery Gap:
  • Provides up to R100,000 per year to cover shortfalls on approved cancer-related claims once you have reached oncology threshold
  • Starts at R160 (single) and R395(family). More Info or contact Discovery below
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DENTISTRY:
Essential Priority
Scheme Benefits Gap benefits
Standard Dentistry:
  • Standard dentistry: from day-to-day benefit
Specialised Dentistry:
  • Specialised dentistry: from day-to-day benefit, limited to R16,300 per person
  • This limit includes claims for orthognathic surgery, dental appliances and their placements
AskAdam Gap:
  • Pays shortfalls and co-payments for in-hospital dentistry treatment approved by scheme
Discovery Gap:
  • 300% scheme rate for specialists
  • Additional R2,500-R20,000 for specialist costs not fully covered by this
  • No benefit for co-payments)
  • Starts at R160 (single) and R395(family). More Info or contact Discovery below
In-Hospital Dentistry: In-hospital:
  • For severe dental and oral surgery, a defined list of procedures is included, with no upfront payment and no overall limit
  • Otherwise, you need to pay a portion of your account upfront:
    • If you are younger than 13, you pay R2,400 for admission to hospital, and R1,100 for admission to a day-clinic
    • If you are 13 and older, you pay R6,200 for admission to hospital, and R4,000 for admission to day-clinic
    • Balance of account is paid by scheme at 100% scheme rate
Orthodontics:
  • See above
Maxillo Facial Surgery:
  • See above
  • See above
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MEDICATION:
Essential Priority
Scheme Benefits Gap benefits
Chronic:
  • Conditions covered:27 CDL conditions
  • Co-payment for use of non-formulary:
  • No benefit, unless PMB
Acute (presrcibed) medication:
  • Schedule 3 and above, from day-to-day benefit, up to the limits below
Main M1 M2 M3
R14,400 R17,000 R20,200 R24,550
  • No benefit, unless PMB
Over-the-counter:
  • From day-to-day benefit
  • These do not add up to the annual threshold, and are not paid for from it
  • No benefit, unless PMB
Birth Control:
  • No benefit, unless PMB
On Discharge:
  • See "Acute Medicine" benefit
  • No benefit, unless PMB
Biological:
  • No benefit, unless PMB level of care
  • No benefit, unless PMB
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OPTOMETRY:
Essential Priority
Scheme Benefits Gap benefits
Optometry:
Limit:R5,000 per person. Paid from day-to-day benefit.
Consult:from above limit
Frames:from above limit
Single lensesfrom above limit
Bifocals:from above limit
Multifocalsfrom above limit
Contactsfrom above limit
Refractive Surgery:from above limit
Notes:20% discount on frames and lenses at network optometrist
AskAdam Gap
  • Pays shortfalls and co-payments for in-hospital or day-clinic treatment approved by scheme
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MENTAL HEALTH:
Essential Priority
Scheme Benefits Gap benefits
In-hospital:
  • Major affective disorders, anorexia and bulimia: 21 days for admissions or 15 out-of-hospital consultations
  • Acute stress disorder accompanied by recent significant trauma: 21 days for admissions or 12 out-of-hospital consultations
  • Other mental health admissions: 21 days in-hospital
  • Alcohol and drug rehab: 21 days in-hospital
  • All admissions are covered in full at a network facility, or at 80% scheme rate at a non-network facility
  • No extra benefit available
Out-of-hospital:
  • See above
  • Otherwise, paid from day-to-day benefit. Claims for psychologists and social workers fall into the supplementary benefit sub limit ie:
M M1 M2 M3+
R6,750 R10,200 R12,700 R15,300
  • No extra benefit available
Trauma:
  • Offers out of hospital claims for recovery after traumatic events for rest of year, and year after that
  • No extra benefit available
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OTHER BENEFITS:
Essential Priority
Scheme Benefits Gap benefits
General Appliances:
  • External appliances limited to R26,450 per family from day-to-day benefit
  • Cochlear implants: R214,500
  • No benefit
1.1. Hearing Aids:
  • R14,100 per family paid from day-to-day benefit
  • No benefit
1.2. Wheelchairs:
  • See "General Appliances" limit
  • No benefit
Dialysis:
  • Covered in full if you use network provider
  • No extra benefit available
HIV:
  • Covered if on the HIV Care program
  • No benefit
Emergency Transport:
  • Discovery 911
  • No benefit
International Insurance:
  • Up to R5 million per person on each journey for emergency medical costs while outside South Africa
  • Emergency medical evacuations from certain sub-Saharan African countries back to South Africa
  • No benefit
Other:
  • Internal nerve stimulators: R153,600
  • DNA Analysis: paid in full from day-to-day benefit or 50% from above threshold
  • Second opinion from Cleveland Clinic for life-threatening and life-changing conditions. 50% co-payment
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WELLNESS/PREVENTATIVE BENEFITS:
Essential Priority
Scheme Benefits Gap benefits
Flu vaccination:
  • Covered, for 65 yrs+
  • No benefit
Pneumonia vaccines:
  • To be confirmed
  • No benefit
Back Rehabilitation Programme: TBC
  • No benefit
Biometric Screening:
  • Covered
  • No benefit
Child Immunisation: TBC
  • No benefit
Pap Smear:
  • Covered, every 3 years
  • No benefit
Mammogram:
  • Covered, every 2 years
  • If you qualify, you can get Breast MRI and once-off BRCA test for breast screening
  • No benefit
PAS Test:
  • Covered
  • No benefit
HIV Test:
  • Covered
  • No benefit
Other:
  • Kids' assessment, including height, weight, head circumference and health and milestone tracking
  • No benefit
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PROSTHETICS:
Essential Priority
Scheme Benefits Gap benefits
Overal Limit:
  • Shoulder joint prostheses: no limit, unless you use non-network supplier, in which case R41,700 limit applies
  • Major joints surgery: no limit, unless you use non-network supplier, in which case 80% scheme rate and R30,000 per prosthesis limit applies
  • Spinal surgery: no limit, unless you use non-network supplier, in which case R25,500 limit for first level and R51,000 for two or more levels. Limted to one procedure per person per year.
AskAdam
  • Sublimit increased by up to R150,000 per person
  • No benefit for procedures excluded by medical aid
Sub-limits: . AskAdam
  • Sublimit increased by up to R150,000 per person
  • No benefit for procedures excluded by medical aid
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    Important!
  • Unless specified, assume that all benefits are paid are paid at 100% scheme rate
  • No limits or co-payments can apply to treatment of PMBs, which is always unlimited, although subject to strict protocols and scheme rules.
  • “Unlimited” benefits are still subject to authorisation, protocols and sublimits
  • Assume that all benefits need to be pre-authorised