Discovery Executive medical aid: 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.

Executive
2018 Costs:
Total Cost pm:

Main member:

R5,950

Adult:

R5,950

Child: (Pay only for first 3)

R1,134
Savings Account (yr): R17,844 R17,844 R3,396
Self Payment Gap:
R2,506 R2,506 R454
Above Threshold:
  • Once your savings are depleted, and you have paid the self payment gap, scheme will cover most out of hospital expenses at scheme rate, with sublimits for some benefits.
2019 Costs:
Total Cost pm:

Main member:

R6,541
(9.93%)

Adult:

R6,541

Child: (Pay only for first 3)

R1,248
Savings: R19,620 R19,620 R3,744
Self Payment Gap:
R3,180 R3,180 R556
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In brief (2018):
  • Scheme rate is 300%, 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.
  • Discovery does pay for most maternity expenses and some preventative benefits such as mammograms and pap smears
  • Unlimited cancer cover, with a co-payment after R400,000
  • Cover for cochlear implants included.
  • Generous benefits for 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:
Executive
Scheme Benefits: Gap Benefits:
Specialists:
  • Up to 300% scheme rate for specialists
  • Contracted Specialists: covered in full
  • GPs and other professionals: 200% scheme rate
  • 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 500% 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 R90 (single) and R150(family) for this plan. More Info or contact Discovery below
Hospital Choice:
  • Choose any hospital
  • No benefit, unless PMB
Specialised Radiology:
  • 100% scheme rate
  • N/A
Supplementary Services: (Physio, etc)
  • 200% 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:
  • 500% of scheme rate for specialists only
  • Additional R2,500-R20,000 for some outstanding costs not covered by scheme
Co-payments:
  • 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:
  • International Second Opinion: members can obtain second opinion from Cleveland Clinic
  • Overseas Treatment Benefit: R750,000 for treatment not available in South Africa, and R300,000 for voluntary in-hospital treatment outside SA (new benefit). Both options have 20% co-payment
  • Specialised medicine and technology: R200,000 per person with a 20% co-payment
  • 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):
Executive
Scheme Benefits Gap benefits
Main: Adult: Child:
Savings /yr: R17,844 R17,844 R3,396
Self Payment:
(per year, if you use up all your savings)
R2,506 R2,506 R454
Above Threshold: Once your savings are depleted, and you have paid the self payment gap, scheme will cover most out of hospital expenses at scheme rate, with sublimits for some benefits.
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
  • If in Self Payment Gap, GP consults and kid casualty visits covered by scheme, if using network provider
  • No benefit, unless PMB
Childcare:
  • If in Self Payment gap, unlimited network GP visits and 2 kid casualty visits covered by scheme if using network providers
  • For two years after birth: two visits for baby with GP, Paediatrician or ENT; one six week post-birth consult with midwife, GP or gynae; one nutritional assessment; two mental health consults; one lactation consult
  • No extra benefit available
Specialists consultations:
  • From day-to-day benefit at up to 300% 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:
  • Paid by scheme
  • No benefit, unless PMB
Supplementary Services: (Physio, etc)
  • From day-to-day benefit
  • Limited to:
    M M1 M2 M3+
    R23,300 R28,000 R32,750 R39,300
  • For a defined list of conditions you get unlimited cover for biokineticists, acousticians, physiotherapists, occupational therapists, and speech and language therapists. Speak to Discovery directly
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:
Executive
Scheme Benefits Gap benefits
Hospital stay:
  • 300% scheme rate
  • Up to R1,880 for private ward
AskAdam Gap:
  • Pays up to 500% scheme rate for specialists, GPs and other medical professionals, in-hospital only
Discovery Gap:
  • 500% of scheme rate for specialists only
  • Additional R2,500-R20,000 for specialist costs not fully covered by this
  • Starts at R90 (single) and R150(family). More Info or contact Discovery below
Consultations:
    Discovery pays for:
  • 12 consults
  • Nuchal translucency or Non-Invasive Prenatal Test
  • Up to R5,000 for registered devices (breast pumps, etc) with 25% co-payment
  • Certain blood tests
  • Five pre- or postnatal classes with registered nurse
  • One lactation consult
  • Antenatal classes: R1,750 per family
  • No benefit, unless PMB
Scans:
    Discovery pays for:
  • 2 x ultrasound scans
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CANCER (ONCOLOGY):
Executive
Scheme Benefits Gap benefits
Overall coverage (in and out of hospital):
  • Unlimited, subject to sublimit below. After the first R400,000, a 20% co-payment applies for non-PMB cancers
  • Specialised medicine and technology, defined list: R200,000 per person with a 20% co-payment
  • 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 R90 (single) and R150(family). More Info or contact Discovery below
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DENTISTRY:
Executive
Scheme Benefits Gap benefits
Standard Dentistry:
  • Standard dentistry: from day-to-day benefit
Specialised Dentistry:
  • Specialised dentistry: from day-to-day benefit, limited to R27,300 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:
  • 500% scheme rate for specialists
  • Additional R2,500-R20,000 for specialist costs not fully covered by this
  • (No benefit for co-payments)
  • Starts at R90 (single) and R150(family). More Info or contact Discovery below
In-Hospital Dentistry:
  • 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 at100% scheme rate and 300% scheme rate for specialists.
Orthodontics:
  • See above
Maxillo Facial Surgery:
  • See above
  • See above
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MEDICATION:
Executive
Scheme Benefits Gap benefits
Chronic:
  • 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+
R38,900 R45,600 R52,200 R58,900
  • 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:
  • For a defined list of latest treatments, limited to R200,000 per person, with a 20% co-payment
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 cover limit). This includes extra cover for biological medicine short-payments or co-payments. More info
Discovery Gap:
  • Up to R100,000 for oncology co-payments if oncology threshold has been reached
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OPTOMETRY:
Executive
Scheme Benefits Gap benefits
Optometry:
Limit:R8,000 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:
Executive
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+
R23,300 R28,000 R32,750 R39,300
  • 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:
Executive
Scheme Benefits Gap benefits
General Appliances:
  • External appliances limited to R58,800 per family from day-to-day benefit
  • Cochlear implants: R223,700
  • No benefit
1.1. Hearing Aids:
  • R24,700 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 $1 million per person for emergency costs while travelling outside South Africa, for a period of 90 days. Excludes pre-existing conditions.
  • Second opinion from Cleveland Clinic: paid for by scheme
  • R750,000 per person for international treatment not available in South Africa, with 20% co-payment
  • R300,000 to cover voluntary in-hospital treatment outside South Africa.
  • No benefit
Other:
  • Internal nerve stimulators: R153,600
  • Trauma recovery: out-of-hospital claims related to certain traumatic events paid until the end of the year following the event
  • DNA Analysis: paid in full from day-to-day benefit or 50% from above threshold
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WELLNESS/PREVENTATIVE BENEFITS:
Executive
Scheme Benefits Gap benefits
Flu vaccination:
  • Covered, for 65yrs+
  • No benefit
Pneumonia vaccines:
  • -
  • No benefit
Back Rehabilitation Programme:
  • -
  • No benefit
Biometric Screening:
  • Covered
  • No benefit
Child Immunisation:
  • -
  • 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:
Executive
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