Discovery Classic Smart medical aid plan: 2020

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Classic Smart
2020 Costs:
Total Cost pm:

Main member:

R1,954

Adult:

R1,542

Child:

R781
Savings (per year):
  • No savings option on this plan



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IN HOSPITAL PROCEDURES:
Classic Smart
Scheme Benefits: Notes and Links:
non-Network Specialists:
  • The Blue Plan gap cover will increase this to 500% scheme rate
network Specialists:
  • Full cover, for contracted specialists
  • The Blue Plan gap cover will increase this to 500% scheme rate
non-Network GPs:
  • Up to 200% scheme rate
  • The Blue Plan gap cover will increase this to 500% scheme rate
network GPs:
  • Full cover, for contracted specialists
  • The Blue Plan gap cover will increase this to 500% scheme rate
Hospital Choice:
Penalty for using other hospital:
  • R8,800 co-payment if you voluntarily choose another hospital
Specialised Radiology:
  • If not related to admission or for conservative back or neck treatment, R3,500 co-payment from day-to-day benefit
Supplementary Services: (Physio, etc)
  • Covered in full for professionals with payment arrangement with Discovery
  • Otherwise, 200% scheme rate
  • The Blue Plan gap cover will increase this to 500% scheme rate
Transplants:
  • Covered
Co-payments:
  • Defined procedures performed outside of Smart day surgery network: R9,650
  • Scopes, in-hospital: R5,000co-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: R68,100 per person, per lifetime
  • Cancer: Unlimited palliative care cover for approved care at home
Casualty:
  • Accident and trauma (emergency) related costs covered
  • Both the Blue Plan and Red Plan gap cover will pay up to R20,000 per person for unpaid casualty costs in event of emergency
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 R157,000 per person per year for all gap benefits (except dread disease and premium waiver benefits which do not count towards the R157,000 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):
Classic Smart
Scheme Benefits Notes and Links:
Main Member: Adult: Child:
Savings /yr: No savings option on this plan
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:
  • GP in Smart Plan Network: unlimited, with R50 co-payment per consult, excluding video call consults, which are covered at 100% scheme rate
  • Sports related injuries: basic x-rays, two specialist consults, and four other consults when referred by a Smart Network GP, with a R100 co-payment for each consult or x-ray
Childcare:
Specialists consultations:
  • No benefit, unless PMB
Pathology:
  • No benefit, unless PMB
General radiology:
  • No benefit, unless PMB
Specialised radiology:
  • R3,500 co-payment
  • , unless PMB
AskAdam Gap:
  • Co-payment benefit pays the co-paymentsfor MRI and CT scans
Discovery Gap:
  • No benefit, unless PMB
Supplementary Services: (Physio, etc)
  • No benefit, unless PMB



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MATERNITY BENEFITS:
Classic Smart
Scheme Benefits Notes and Links:
Hospital stay:
  • 200% scheme rate for specialists
  • The Blue Plan gap cover will increase this to 500% scheme rate
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



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CANCER (ONCOLOGY):
Classic Smart
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



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DENTISTRY:
Classic Smart
Scheme Benefits Notes and Links:
Standard Dentistry:
  • Standard dentistry: one consult with R100 co-payment
  • Consider getting Primary Health Care (medical insurance) that will cover you for a lot of out of hospital claims, including standard dentistry like scaling, polishing, fillings, extractions, root canals and more. It's an excellent complement to a hospital plan.
  • R370/main | R245/adult | R110/child
  • Read more here
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 R2,650 for admission to hospital, and R1,200 for admission to a day-clinic
    • If you are 13 and older, you pay R6,800 for admission to hospital, and R4,380 for admission to day-clinic
    • Balance of account is paid by scheme at 100% scheme rate
Orthodontics:
  • See above
Maxillo Facial Surgery:
  • See above



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MEDICATION:
Classic Smart
Scheme Benefits: Notes and Links:
Chronic:
  • Conditions covered:27 CDL conditions
  • Co-payment for use of non-formulary:
Acute (presrcibed) medication:
  • R1,500 per person and R2,500 per family
  • For schedule 3 and above, prescribed by network GP
  • Consider getting Primary Health Care (medical insurance) that will cover you for all GP visits, some specialist visits, acute meds, minor out of hospital procedures, some radiology and pathology, dentistry, optometry and more. It's an excellent complement to a hospital plan.
  • R370/main | R245/adult | R110/child
  • Read more here
Over-the-counter:
  • No benefit
Birth Control:
  • No benefit
On Discharge:
  • No benefit
Biological:
  • No benefit, unless PMB level of care



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OPTOMETRY:
Classic Smart
Scheme Benefits: Notes and Links:
Optometry:
Limit:R0
Consult:1 test per person with R50 co-payment
Frames:
Single lenses
Bifocals:
Multifocals
Contacts
Refractive Surgery:
Notes:20% discount on frames and lenses at a network optometrist



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MENTAL HEALTH:
Classic Smart
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
Trauma:
  • Offers out of hospital claims for recovery after traumatic events for rest of year, and year after that



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OTHER BENEFITS:
Classic Smart
Scheme Benefits Notes and Links:
General Appliances:
  • Cochlear implants: R223,700
  • Internal nerve stimulators: R153,600
  • Otherwise, from day-to-day benefit
1.1. Hearing Aids:
  • No benefit
1.2. Wheelchairs:
  • No benefit
Dialysis:
  • Covered in full if you use network provider
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



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WELLNESS/PREVENTATIVE BENEFITS:
Classic Smart
Scheme Benefits: Notes and Links:
Flu vaccination:
  • Covered, for 65 yrs+
Pneumonia vaccines:
  • To be confirmed
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



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PROSTHETICS:
Classic Smart
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: .



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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