How Discovery pays for chronic conditions
By law, every medical aid must cover the diagnosis, treatment and ongoing care of 27 chronic conditions, called the Chronic Disease List (CDL). Read more about Prescribed Minimum Benefits here.
First, get approved
Your GP must apply to Discovery’s Chronic Illness Benefit for you. Discovery only pays chronic claims from this benefit once your condition is approved.
Tests to diagnose your condition
If you’re newly diagnosed, Discovery pays in full for the diagnostic tests and the consultation where you were diagnosed. This applies only if you were a member when you were diagnosed and your doctor puts the correct diagnosis code on the claim.
Ongoing tests and check-ups
Each condition has a “basket”: a set number of tests and specialist visits Discovery pays for each year. The numbers are pro-rated from the date you were approved. If two of your conditions include the same test, you get the higher number, not both added together.
Radiologists, dietitians and podiatrists are paid in full. Pathologists are paid in full if they have an agreement with Discovery; if not, Discovery pays up to its own rate and you pay the difference.
GP visits
On all plans, Discovery pays for 4 GP visits a year for your chronic condition, in full, at a network GP.
- Executive: any GP in the Discovery network.
- All other plans: you must nominate one GP from your plan’s network to manage your condition. You can change your GP up to 3 times a year.
If you use any other GP, Discovery pays up to 80% of its rate and you pay the rest.
Specialist visits
The number of specialist visits depends on your condition. Specialists in Discovery’s network are paid in full. If you use a specialist outside the network:
- Executive, Classic Comprehensive, Priority, Saver and Core: Discovery pays up to 100% of its rate.
- Classic Smart Comprehensive, Smart Saver, Smart and KeyCare: Discovery pays up to 80% of its rate.
KeyCare members must use a KeyCare network specialist to be covered in full.
When claims come from your day-to-day benefits instead
Claims come out of your savings or day-to-day benefits, not your chronic cover, if:
- the claim has no diagnosis code, or
- you’ve used up the number of tests or visits in your basket.
Tip: ask your doctor to put your diagnosis code on every claim and every referral to a lab or radiologist.
Medicine
Each plan has a medicine list. Discovery pays in full for medicine on the list. For medicine not on the list, Discovery pays up to a monthly limit, which depends on your plan.
Full list of tests per condition
Discovery’s brochure lists every test and visit covered for each condition: Treatment baskets for the CDL conditions (Discovery)
Note: this brochure is hosted by Discovery, not rehealth, so Discovery can remove or move it without notice. If the link is broken, please let us know at info@rehealth.co.za.
The 27 Chronic Disease List conditions (all plans)
- Addison’s disease
- Asthma
- Bipolar mood disorder
- Bronchiectasis
- Cardiomyopathy
- Chronic renal disease
- COPD
- Cardiac failure
- Coronary artery disease
- Crohn’s disease
- Diabetes insipidus
- Diabetes type 1
- Diabetes type 2
- Dysrhythmia
- Epilepsy
- Glaucoma
- Haemophilia
- HIV/AIDS
- Hyperlipidaemia
- Hypertension
- Hypothyroidism
- Multiple sclerosis
- Parkinson’s disease
- Rheumatoid arthritis
- Schizophrenia
- Systemic lupus erythematosus
- Ulcerative colitis
Additional conditions: Executive and Classic Comprehensive only
The law doesn’t require these. Discovery covers medicine only for them, up to a monthly limit, with no medicine list.
- Ankylosing spondylitis
- Behçet’s disease
- Cystic fibrosis
- Delusional disorder
- Dermatopolymyositis
- Generalised anxiety disorder
- Huntington’s disease
- Isolated growth hormone deficiency
- Major depression
- Motor neuron disease
- Muscular dystrophy and other inherited myopathies
- Myasthenia gravis
- Obsessive compulsive disorder
- Osteoporosis
- Paget’s disease
- Panic disorder
- Polyarteritis nodosa
- Post-traumatic stress disorder
- Psoriatic arthritis
- Pulmonary interstitial fibrosis
- Sjögren’s syndrome
- Systemic sclerosis
