Self Payment Gap: (What you need to pay out of pocket before you can access the "Above Threshold" benefit)
R14,754
R10,814
R4,368
"Above Threshold" benefit (ATB): Additional cover the scheme makes available to you, once you've paid the self payment gap.
R19,370
R13,820
R6,770
Children Rates:
Under 21 yrs old
Only pay for 3 children
Note:
Exclusions: Note that all schemes have extensive exclusions. We've tried to list the major ones, but you must consult with your scheme to get the full list.
All treatments and procedures are subject to authorisation and protocols
All benefits are listed as an indication only. Please verify with your broker and scheme
In-hospital dentistry: co-payment required for some admissions. See dentistry benefit for details
If any of these are out of hospital: no co-payment
Scopes (Gastroscopy, colonoscopy, sigmoidoscopy and proctoscopy):
No co-payment if:
Done in doctor's rooms
Part of confirmed PMB condition
Patient is under 12yrs
Otherwise
Day clinic: R4,300 co-payment
Hospital: R6,900 co-payment, or R5,600 if done by a doctor who is part of "value-based network".
You must use a facility from Day Surgery Network, or pay an additional R6,650-R6,900
If gastroscopy and colonoscopy are performed in same admission:
Day clinic: R5,250 co-payment
Hospital: R8,650 co-payment, or R7,050 if done by a doctor who is part of "value-based network".
You must use a facility from Day Surgery Network, or pay an additional R8,650
* There might be other co-payments if you don't use scheme-chosen provider for some services.
* Treatment required for PMB level care is always paid by scheme, with no co-payment, if you follow the protocols. That means that these co-payments might not apply in your case! More info here
Specialised Radiology:
MRI and CT scans, Part of approved admission: Covered by scheme
MRI and CT scans, Not part of approved admission R3,670 co-payment
No limits or co-payments for PMB level care and/or for emergency
Supplementary Services: (Physio, etc)
Covered in full for professionals with payment arrangement with Discovery
Otherwise, 100% scheme rate
No limits or co-payments for PMB level care and/or for emergency
Transplants:
Covered
Dialysis:
Covered
Exclusions:
* Treatment required for PMB level of care is always paid by scheme, if you follow the protocols. It cannot be excluded. More info here.
* All schemes have extensive exclusions. We've tried to list the major ones here, but please consult your scheme or broker to get the full list
Alternatives to hospitals:
Palliative care at home: Unlimited, as approved
Physical and virtual 24-hour care for services such as postnatal care, end-of-life care, IV infusions (drips), COVID-19 and wound care.
International Second Opinion for life-threatening and life-changing condition: members can obtain second opinion from Cleveland Clinic, with a 25% co-payment
All medical aids must pay for the diagnosis, treatment and management of all PMB conditions, in or out of hospital. You can see a full list of the conditions here.
This can include consults with specialists, blood or other tests, radiology and medicine
The benefit is paid by the scheme, and not out of your savings account
If you have no day-to-day funds, you still have cover for PMBs
Schemes usually impose the use of specific providers for treatment of PMBs. Read more about that here.
Access to the WELLTH Fund. You get up to R10,000 per family for various out of hospital expenses including GP, eye, dental, hearing screenings and medical devices. Find out more .
All benefits, including gap benefits, are subject to treatments and procedures being authorised by medical scheme. The benefits listed here are an indication only. Please verify all benefits and their conditions with the scheme.
You might be required to use specific pharmacies and be limited to specific medicines
Acute (presrcibed) medication:
Schedule 3 and above
From day-to-day benefit, up to the limits below:
M= R18,150 M1= R21,500 M2= R25,500 M3+= R31,050
Over-the-counter:
From day-to-day benefit
These do not add up to the annual threshold, and are not paid for from it
Birth Control:
See "Acute Medicine" benefit
On Discharge:
See "Acute Medicine" benefit
Biological:
PMBs only
Treatment that is required (by law) for PMB conditions is always paid paid by scheme, with no co-payment, if you follow the protocols. More info here.)
Note:
Schemes have very strict rules about where you can get your medicine to get full benefit. We do not list the requirements here, so confirm with your scheme before you collect your medicine.
Formulary: A pre-defined list of approved medicines. Each plan has a different list, and might not pay for non-listed medicine. Confirm with your scheme whether your required medicine is covered by them.
PMBs: Prescribed Minimum Benfits. To read more about PMBs click here
DSPs: Designated Service Provders. Where stipulated, you must use specific specific providers to get full benefit.
Co-payment: Paid out of pocket, or out of savings account. Sometimes this is refundable to you if you have a gap product
All benefits, including gap benefits, are subject to treatments and procedures being authorised by medical scheme. The benefits listed here are an indication only. Please verify all benefits and their conditions with the scheme.
A quick guide to how you can change your medical aid plan, including the resignation procedure, and things to look out for, such as imposed waiting periods from your new scheme
