Discovery Core Coastal medical aid plan: 2019

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Coastal Core
2019 Costs:
Total Cost pm:

Main member:

R1,770

Adult:

R1,330

Child: (Pay only for first 3)

R704
Savings (per year):
  • No savings option on this plan
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In brief (2018):
  • Scheme rate is 100%, but you pay for most out of hospital claims yourself (except PMB claims)
  • 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
  • Cover for cochlear implants and travel insurance is included.
  • 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:
Coastal Core
Scheme Benefits: Notes and Links:
Specialists:
  • Up to 100% scheme rate
  • Contracted Specialists: covered in full
  • You or gap cover pay the balance, if any
Gap Cover
  • Gap cover is available for this plan. Budget about R350 for a fully comprehensive gap cover that will increase the scheme rate to 500% and pay most co-payments and increase sublimits.
Hospital Choice:
  • Choose a selected private hospitals in coastal provinces
  • Otherwise, Discovery pays for no cover if a non-selected hospital is used in coastal province, or 70% cover if a hospital is used outside the coastal provinces.
Specialised Radiology:
  • If not related to admission or for conservative back or neck treatment: no benefit
  • Otherwise, 100% scheme rate
Supplementary Services: (Physio, etc)
  • Covered in full for professionals with payment arrangement with Discovery
  • Otherwise, 100% scheme rate
Transplants:
  • Covered
Co-payments:
  • Defined procedures performed outside of day surgery network: R7,650
  • Scopes, in-hospital: R4,550 co-payment
  • No co-payment if done in doctor's rooms
  • This applies to gastroscopy, colonoscopy, sigmoidoscopy and proctoscopy
  • In-hospital dentistry: co-payment required for some admissions. See dentistry benefit for details
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
Casualty:
  • Accident and trauma (emergency) related costs covered
Other:
  • Cochlear implants: R214,500
  • Internal Nerve stimulators: R147,300
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)
What next?
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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):
Coastal Core
Scheme Benefits Notes and Links:
Main Member: Adult: Child:
Savings /yr: No savings option on this plan
General info:
GP consultations:
  • No benefit, unless PMB
Childcare:
Specialists consultations:
  • No benefit, unless PMB
Pathology:
  • No benefit, unless PMB
General radiology:
  • No benefit, unless PMB
Specialised radiology:
  • No benefit, unless PMB
Supplementary Services: (Physio, etc)
  • No benefit, unless PMB
What next?
We will email you a quote for this and two other comparable plans. No phone calls.

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MATERNITY BENEFITS:
Coastal Core
Scheme Benefits Notes and Links:
Hospital stay:
  • 100% scheme rate for specialists
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
Scans:
    Discovery pays for:
  • 2 x ultrasound scans
What next?
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CANCER (ONCOLOGY):
Coastal Core
Scheme Benefits Notes and Links:
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
What next?
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DENTISTRY:
Coastal Core
Scheme Benefits Notes and Links:
Standard Dentistry:
  • Standard dentistry: no benefit
Specialised Dentistry:
  • Specialised dentistry: no benefit. This includes claims for orthognathic surgery, dental appliances and their placements
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:
  • No benefit
Maxillo Facial Surgery:
  • No benefit for orthognathic surgery related accounts
What next?
We will email you a quote for this and two other comparable plans. No phone calls.

Together with a financial advisor, we can help you with unpaid claims, findinging a gap cover, general advice, plan changes, cheaper options and more. FREE.

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MEDICATION:
Coastal Core
Scheme Benefits: Notes and Links:
Chronic:
  • Conditions covered:27 CDL conditions
  • Co-payment for use of non-formulary:
Acute (presrcibed) medication:
  • No benefit
Over-the-counter:
  • No benefit
Birth Control:
  • No benefit
On Discharge:
  • No benefit
Biological:
  • No benefit, unless PMB level of care
What next?
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OPTOMETRY:
Coastal Core
Scheme Benefits: Notes and Links:
Optometry:
Limit:No benefit
Consult:n/a
Frames:n/a
Single lensesn/a
Bifocals:n/a
Multifocalsn/a
Contactsn/a
Refractive Surgery:n/a
Notes:20% discount on frames and lenses at a network optometrist
What next?
We will email you a quote for this and two other comparable plans. No phone calls.

Together with a financial advisor, we can help you with unpaid claims, findinging a gap cover, general advice, plan changes, cheaper options and more. FREE.

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MENTAL HEALTH:
Coastal Core
Scheme Benefits Notes and Links:
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
Out-of-hospital:
  • See above
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Trauma:
  • No benefit, unless PMB
What next?
We will email you a quote for this and two other comparable plans. No phone calls.

Together with a financial advisor, we can help you with unpaid claims, findinging a gap cover, general advice, plan changes, cheaper options and more. FREE.

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OTHER BENEFITS:
Coastal Core
Scheme Benefits Notes and Links:
General Appliances:
  • Cochlear implants: R223,700
  • Internal nerve stimulators: R153,600
  • Otherwise, from day-to-day benefit
  • No benefit
1.1. Hearing Aids:
  • No benefit
1.2. Wheelchairs:
  • No benefit
Dialysis:
  • Covered in full if you use network provider
HIV:
  • Covered if on the HIV Care program
Emergency Transport:
  • Discovery 911
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
Other:
  • Internal nerve stimulators: R153,600
  • Second opinion from Cleveland Clinic for life-threatening and life-changing conditions. 50% co-payment
What next?
We will email you a quote for this and two other comparable plans. No phone calls.

Together with a financial advisor, we can help you with unpaid claims, findinging a gap cover, general advice, plan changes, cheaper options and more. FREE.

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WELLNESS/PREVENTATIVE BENEFITS:
Coastal Core
Scheme Benefits: Notes and Links:
Flu vaccination:
  • Covered, for 65 yrs+
Pneumonia vaccines:
  • To be confirmed
Back Rehabilitation Programme: TBC
Biometric Screening:
  • Covered
Child Immunisation: TBC
Pap Smear:
  • Covered, every 3 years
Mammogram:
  • Covered, every 2 years
  • If you qualify, you can get Breast MRI and once-off BRCA test for breast screening
PAS Test:
  • Covered
HIV Test:
  • Covered
Other:
  • Kids' assessment, including height, weight, head circumference and health and milestone tracking
What next?
We will email you a quote for this and two other comparable plans. No phone calls.

Together with a financial advisor, we can help you with unpaid claims, findinging a gap cover, general advice, plan changes, cheaper options and more. FREE.

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PROSTHETICS:
Coastal Core
Scheme Benefits: Notes and Links:
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.
Sub-limits: .
What next?
We will email you a quote for this and two other comparable plans. No phone calls.

Together with a financial advisor, we can help you with unpaid claims, findinging a gap cover, general advice, plan changes, cheaper options and more. FREE.


    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