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HEALTH PLAN GUIDEKEYCAREPLANSHealthcare for your life
DISCOVERY HEALTHMEDICAL SCHEMEDiscovery Health Medical Scheme provides health plans thatare as unique as you are. Seamless, personalised, connected healthcover to protect you and those that you care for most, at everystage of your life.Read this guide to understand how your chosen health plan works including: What to do when you need to go to a doctor or to a hospital The preventative screening, medical conditions and treatments that we cover The payment rules for medicine and other treatments Which benefits you need to apply for and if there are any limits for certain benefits The medical conditions and treatments that we do not cover ips for you to conveniently manage and access all the information for your chosenThealth plan using the Discovery app and websiteThe benefits explained in this brochure are provided by Discovery Health Medical Scheme, registration number 1125, administered by Discovery Health (Pty) Ltd, registration number 1997/013480/07, an authorised financial services provider.This brochure is only a summary of the key benefits and features of Discovery Health Medical Scheme plans, awaiting formal approval from the Council for Medical Schemes. In all instances, Discovery Health Medical Scheme Rules prevail.Please consult the Scheme Rules on www.discovery.co.za. When reference is made in this brochure to “we” in the context of benefits, members, payments or cover, this refers to Discovery Health Medical Scheme. We are continuously improvingour communication to you. The latest version of this guide as well as detailed benefit information is available on www.discovery.co.za.
GLOSSARYKEY TERMSCABOUT SOME OF THE TERMS WE USE IN THIS DOCUMENT C HRONIC ILLNESS BENEFIT (CIB) D ESIGNATED SERVICE PROVIDER (DSP) he Chronic Illness Benefit (CIB) covers you for a defined list of chronicTconditions. You need to apply to have your medicine and treatmentcovered for your chronic condition.CO-PAYMENT his is an amount that you need to pay towards a healthcare service. The amountTcan vary by the type of covered healthcare service, place of service, the age ofthe patient or if the amount the service provider charges is higher than the ratewe cover. If the co-payment amount is higher than the amount charged for thehealthcare service, you will have to pay for the cost of the healthcare service.COVER over refers to the benefits you have access to and how we pay for theseChealthcare services such as consultations, medicine and hospitals, on yourhealth plan. healthcare provider (for example doctor, specialist, pharmacist or hospital)Awho we have an agreement with to provide treatment or services at acontracted rate. Visit www.discovery.co.za or click on Find a provideron the Discovery app to view the full list of DSPs. D ISCOVERY HEALTH RATE (DHR) This is a rate we pay for healthcare services from hospitals, pharmacies,healthcare professionals and other providers of relevant health services.This rate may vary depending on the plan you choose. D ISCOVERY HEALTH RATE FOR MEDICINE his is the rate we pay for medicine. It is the Single Exit PriceTof medicine plus the relevant dispensing fee. D ISCOVERY HOME CARE iscovery Home Care is an additional service that offers you qualityDhome-based care in the comfort of your home for healthcare serviceslike IV infusions, wound care, post-natal care and advanced illness care.D DAY-TO-DAY BENEFITS ou have cover for a defined set of day-to-day medical expenses suchYas medically appropriate GP consultations, blood tests, X-rays or medicinein our KeyCare networks. D EDUCTIBLE Depending on the plan you choose, this is the amount that you must payupfront to the hospital or day clinic for specific treatments/procedures or ifyou use a facility outside of the network. If the upfront amount is higher thanthe amount charged for the healthcare service, you will have to pay for thecost of the healthcare service.EEMERGENCY MEDICAL CONDITIONAn emergency medical condition, also referred to as an emergency, is the sudden and, at the time unexpected onset of a health conditionthat requires immediate medical and surgical treatment, where failureto provide medical or surgical treatment would result in serious impairmentto bodily functions or serious dysfunction of a bodily organ or part or wouldplace the person’s life in serious jeopardy. n emergency does not necessarily require a hospital admission.AWe may ask you for additional information to confirm the emergency.Discovery Home Care is a service provider. Practice 080 000 8000190, Grove Nursing Services (Pty) Ltd registration number 2015/191080/07, trading as Discovery HomeCare.Find a healthcare provider and Discovery HealthID is brought to you by Discovery Health (Pty) Ltd; registration number 1997/013480/07, an authorised financial services provider and administrator of medical schemes
GLOSSARYFFIND A HEALTHCARE PROVIDERPFind a healthcare provider is a medical and provider search tool which is available on the Discovery app or website www.discovery.co.za.The Scheme has payment arrangements with various healthcare professionals and providers to ensure that you can get full cover with no co-payments.PREMIER PLUS GPH HEALTHIDHealthID is an online digital platform that gives your doctor fast, up-to-date A Premier Plus GP is a network GP who has contracted with us to provide you with coordinated care for your defined chronic conditions.access to your health information. Once you have given consent, your doctor canuse HealthID to access your medical history, make referrals to other healthcareprofessionals and check your relevant test results.PRESCRIBED MINIMUM BENEFITS (PMB)I n terms of the Medical Schemes Act of 1998 (Act No. 131 of 1998) and its Regulations, allmedical schemes have to cover the costs related to the diagnosis, treatment and care of:M MEDICINE LIST (FORMULARY)An emergency medical conditionA list of medicine we cover in full for the treatment of approved chronic A defined list of 270 diagnosescondition(s). This list is also known as a formulary.A defined list of 27 chronic conditions. o access Prescribed Minimum Benefits, there are rules defined by the CouncilTfor Medical Schemes (CMS) that apply:N NETWORKSYou may need to make use of specific hospitals, pharmacies, doctors or specialists in a network. We have payment arrangements with these providersto ensure you get access to quality care at an affordable cost. By using networkproviders, you can avoid having to pay additional costs and co-payments yourself.Hospital NetworksYou have chosen a plan with ahospital network, make sure youuse a hospital in that network toget full cover.Day surgery NetworksFull cover for a defined listof procedures in our daysurgery network.PAYMENT ARRANGEMENTSDoctor NetworksYou have full cover for GPsand specialists in our networks whowe have payment arrangementswith.Medicine NetworksUse a pharmacy in our network to enjoyfull cover and avoid co-payments whenclaiming for chronic medicine on theprescribed medicine list. Your medical condition must qualify for cover and be part of the defined list of Prescribed Minimum Benefit conditions The treatment needed must match the treatments in the defined benefits You must use Designated Service Providers (DSPs) in our network. This does not apply in emergencies. Where appropriate and according to the rules of the Scheme,you may be transferred to a hospital or other service providers in our network, onceyour condition has stabilised. If you do not use a DSP we will pay up to 80% of theDiscovery Health Rate (DHR). You will be responsible for the difference betweenwhat we pay and the actual cost of your treatment. If your treatment doesn’t meet the above criteria, we will pay according to your plan benefits.RRELATED ACCOUNTSAny account other than the hospital account for in-hospital care. This could include the accounts for the admitting doctor, anaesthetist and any approved healthcareexpenses like radiology or pathology.W WHO GLOBAL OUTBREAK BENEFIT he WHO Global Outbreak Benefit provides cover for global disease outbreaks recognised byTthe World Health Organization (WHO) such as COVID-19. This benefit offers cover for out-ofhospital management and appropriate supportive treatment during the outbreak period.
KEYCARE PLANS01 KEY FEATURES02 EMERGENCIES AND PMBs03 SCREENING AND PREVENTION04 DAY-TO-DAY BENEFITS05 MATERNITY BENEFITS06 CHRONIC AND CANCER BENEFITS07 HOSPITAL BENEFITS08 EXTRA BENEFITS09 CONTRIBUTIONSKEYCAREThere are three KeyCare plan options:KeyCare Plus KeyCare Core KeyCare Start10 VALUE-ADDED OFFERS
EMERGENCYSCREENINGDAY-TO-DAYKEY FEATURESKEY FEATURESMATERNITYCHRONIC AND CANCERHOSPITALUNLIMITED COVER FORHOSPITAL ADMISSIONSUnlimited hospital cover in ourKeyCare hospital networks.EXTRA BENEFITSCONTRIBUTIONSVALUE-ADDED OFFERSFULL COVER FORCHRONIC MEDICINESEssential cover for chronic medicineon the KeyCare medicine list for allChronic Disease List (CDL) conditionswhen you use a Designated ServiceProvider (DSP). Cover dependson the plan you choose.FULL COVER IN HOSPITALFOR SPECIALISTSGuaranteed full cover in hospitalfor specialists on the KeyCarenetwork, and up to 100% of theDiscovery Health Rate (DHR) forother healthcare professionals.EXTENSIVE COVERFOR PREGNANCYYou get comprehensive benefitsfor maternity and early childhoodthat cover certain healthcareservices before and after birth.DAY-TO-DAY COVERUnlimited cover for medicallyappropriate GP consultations,blood tests, X-rays or medicinein our KeyCare networks on theKeyCare Plus and KeyCare Start plans.Vitality is a separate wellness product sold and administered by Discovery Vitality (Pty) Ltd, registrationnumber 1999/007736/07, an authorised financial services provider.SCREENING ANDPREVENTIONScreening and prevention benefitsthat cover vital tests to detect earlywarning signs of serious illness.06
KEY FEATURESKEY IC AND CANCERHOSPITALEXTRA BENEFITSCONTRIBUTIONSVALUE-ADDED OFFERSThe benefits on the differentKeyCare plansThe three plan options have differences in benefits, as shown in the table.All other benefits not mentioned in the table are the same across all plan options.Day-to-day coverPlusCoreStartDay-to-day cover at your chosen KeyCare GP.Medicine from our medicine list is covered in at anetwork pharmacySpecialists are covered up to R4 400 per person peryear. This plan does not offer any additional day-today coverPrimary care is covered at your chosen KeyCareStart GPSpecialists are covered up to R4 400 per person peryear, if you are referred by your KeyCare Network GPNon-emergency casualty visitsCover for one casualty visit per person per yearin any casualty unit at a hospital in the KeyCarenetwork. Unlimited for emergenciesMedicine from our medicine list is coveredin full if you use a network pharmacyTwo specialist visits up to R2 200 per person per year,if you are referred by your KeyCare Start Network GPNot coveredWe cover after-hours care at your chosenKeyCare Start GP or network providerAny KeyCare Network GP can prescribe yourapproved chronic medicine and you mustget your approved chronic medicine froma pharmacy in the networkYour chronic medicine is covered in a state facilityYou pay the first R390 of the consultation.You must get approval before your visitChronic medicineprescriptionsYour approved chronic medication must bedispensed by your KeyCare GP, or you must getyour approved chronic medicine from a pharmacyin the networkCancerWe cover your treatment if it is a Prescribed Minimum Benefit (PMB). You must use a network providerYour treatment is covered in a state facilityChronic DialysisYou must use a network provider once you are registered, or you can go to a state facility.If you go elsewhere we will pay 80% of the Discovery Health Rate (DHR)You are covered at a provider in a state facilityFull Cover Hospital NetworkWe pay up to the Discovery Health Rate (100%)We pay the Discovery Health Rate (DHR)at your chosen KeyCare Start Network HospitalPartial Cover Hospital NetworkWe pay up to 70% of the hospital account and you must pay the balance of the account.No cover for non-emergency admissionsIf the admission is a Prescribed Minimum Benefit (PMB), we will pay 80% of the Discovery Health Rate (DHR)Defined list of proceduresin a day surgery networkCovered in the KeyCare Day Surgery NetworkCovered in the KeyCare Start Day Surgery Network07
EMERGENCY COVERKEY FEATURESEMERGENCYSCREENINGWhat is a medicalemergency?An emergency medical condition, also referredto as an emergency, is the sudden and unexpectedonset of a health condition that requires immediatemedical and surgical treatment. Failure to providemedical or surgical treatment would result inserious impairment to bodily functions or seriousdysfunction of a bodily organ or part or would placethe person’s life in serious jeopardy.An emergency does not necessarily requirea hospital admission. We may ask you or yourtreating provider for additional informationto confirm the emergency.DAY-TO-DAYMATERNITYCHRONIC AND CANCEREmergency coverEmergencies are covered in full.If you have an emergency, you cango straight to hospital. If you needmedically equipped transport,like an ambulance call:0860 999 911Emergency AssistWhat we pay forWe pay for all of the following medical servicesthat you may receive in an emergency:the ambulance (or other medical transport)the account from the hospital the accounts from the doctor who admittedyou to the hospitalthe anaesthetistAssistance during or after a traumatic eventYou have access to dedicated assistance in theevent of a traumatic incident or after a traumaticevent. By calling Emergency Assist you and yourfamily have access to trauma support 24 hours aday. This service also includes access to counselingand additional benefits for trauma related togender-based violence.any other healthcare provider that we approve.Click on Emergency Assiston your Discovery appHOSPITALEXTRA BENEFITSCONTRIBUTIONSVALUE-ADDED OFFERSPrescribed MinimumBenefits (PMB)Prescribed Minimum Benefit (PMB) conditions in terms ofthe Medical Schemes Act 131 of 1998 and its Regulations,all medical schemes have to cover the costs related to thediagnosis, treatment and care of: An emergency medical condition A defined list of 270 diagnoses A defined list of 27 chronic conditions.To access Prescribed Minimum Benefits, there are rulesdefined by the Council for Medical Schemes (CMS) that apply: Your medical condition must qualify for coverand be part of the defined list of PrescribedMinimum Benefit conditions The treatment needed must matchthe treatments in the defined benefits You must use Designated Service Providers (DSPs)in our network. This does not apply in emergencies.Where appropriate and according to the rules of theScheme, you may be transferred to a hospital or otherservice providers in our network, once your conditionhas stabilised. If you do not use a DSP we will pay upto 80% of the Discovery Health Rate (DHR). You will beresponsible for the difference between what we payand the actual cost of your treatment.If your treatment doesn’t meet the above criteria, we willpay according to your plan benefits.The Discovery app is brought to you by Discovery Health (Pty) Ltd; registration number 1997/013480/07, an authorised financial services provider and administrator of medical schemes.08
EMERGENCYSCREENING AND PREVENTIONKEY FEATURESSCREENINGDAY-TO-DAYMATERNITYCHRONIC AND CANCERHOSPITALEXTRA BENEFITSCONTRIBUTIONSVALUE-ADDED OFFERSYou have access to essential screeningand prevention benefitsWe cover various screening tests at our wellness providers.This benefit pays for certain tests that can detect early warning signsof serious illnesses. We cover various screening tests at our wellness providers,for example, blood glucose, cholesterol, HIV, Pap smears, mammogramsand prostate screenings.SCREENING FOR KIDSThis benefit covers growth assessment tests, including height, weight,head circumference and health and milestone tracking at any one ofour wellness providers.SCREENING FOR ADULTSThis benefit covers certain tests such as blood glucose, blood pressure,cholesterol, body mass index and HIV screening at one of our wellness providers.We also cover a mammogram every two years, a Pap smear once every threeyears, PSA test (prostate screening) each year and bowel cancer screening testsevery two years for members between 45 and 75 years.SCREENING FOR SENIORSIn addition to the screening for adults, members aged 65 years and older havecover for a group of age appropriate screening tests in our defined pharmacy network. Cover includes hearing and visual screening and a falls risk assessment, formembers 65 years and older. You may have cover for an additional GP consultationat a Premier Plus GP, depending on your screening test results and if you meet theScheme’s clinical entry criteria.View a list of our wellness providerson our website www.discovery.co.zaHOW WE PAYThese tests are paid from the Screening and Prevention Benefit. Consultationsthat do not form part of PMBs will be paid from your available day-to-day benefits.ADDITIONAL TESTSClinical entry criteria apply tothese tests: efined diabetes andDcholesterol screening tests reast MRI or mammogramBand once-off BRCA testingfor breast screening Colonoscopy for bowelcancer screening ap smear for cervicalPscreening.Seasonal flu vaccine for memberswho are: Pregnant 65 years or older Registered for certain chronicconditions Healthcare professionals(given the potential exposureto COVID-19).Visit www.discovery.co.zato view the detailed Screeningand Prevention benefit guide.09
DAY-TO-DAY BENEFITSKEY IC AND CANCERHOSPITALEXTRA BENEFITSCONTRIBUTIONSVALUE-ADDED OFFERSYour day-to-day coverYou have access to the following day-to-day cover on KeyCare Plus and KeyCare Start plans. On KeyCare Start your chosen KeyCare Start GP must refer youand you must use providers in your chosen KeyCare Start network.Day-to-day coverWhat we payGP visitsYou have unlimited cover for medically appropriate GP consultations. When joining, you must choose a GP from the KeyCare or KeyCare StartGP network, depending on the plan you choose. You must go to your chosen GP for us to cover your consultations, including some minorprocedures. Preauthorisation is required after your 15th GP visit.Blood, urine and other fluid and tissue testsWe pay for a list of blood, urine and other fluid and tissue tests from a network provider. Your chosen GP must ask for these tests by fillingin a KeyCare pathology form.Day-to-day medicineWe pay for medicine from our medicine list if they are prescribed and/or dispensed by your chosen KeyCare Network GP or chosen KeyCare Startnetwork GP, depending on the plan you choose.Basic X-raysWe pay for a list of basic X-rays at a network provider. Your chosen GP must ask for the X-rays to be done.Out-of-network GP visitsOn KeyCare Plus, if you need to see a doctor and your chosen GP is not available, each person on your plan can go to any GP for an out-ofnetwork visit. On KeyCare Start you can go to any KeyCare Network GP for an out-of-nework visit. Out-of-network GP visits are limited to fourvisits per person on KeyCare Plus and two per person on KeyCare Start each year, covered up to the DHR, depending on the plan you choose.We will cover the GP visit, selected blood tests and X-rays, and medicine on our medicine list.Eye careWe cover one eye test for each person, but you must go to an optometrist in the KeyCare Optometry Networks. The optometrist will havea specific range of glasses which you can choose from. You can get a set of contact lenses instead of glasses if you choose to. You can getnew glasses or contact lenses every 24 months.DentistryWe cover consultations, fillings and tooth removals at a dentist in our dentist network. Certain r
Discovery Health Medical Scheme provides health plans that are as unique as you are. Seamless, personalised, connected health cover to protect you and those that you care for most, at everyFile Size: 2MB
