Discovery Health Smart Series

Discovery Health Essential Dynamic Smart Plan – a Digital-First

👉 On the Essential Dynamic Smart plan, you can access Ask Discovery, which will dynamically direct you to the most appropriate hospital in our network, given your current healthcare needs.

👉 Ask Discovery also identifies specialists affiliated with specific Essential Dynamic Smart network hospitals to provide you with comprehensive cover options.

👉 Furthermore, you can request the following from Ask Discovery:

• ➡️ View your plan details and understand your plan benefits.
• ➡️ Find a healthcare provider
• ➡️ Find approved hospitals in the Essential Dynamic Smart Hospital Network.
• ➡️ Book consultations with approved providers associated with the Smart network.

👉 Members of the Essential Dynamic Smart Plan also have the following benefits:

• ➡️ Hospital Benefits
• ➡️ This includes cover for both unplanned and emergency admissions.
• ➡️ Medical Benefits
• ➡️ This includes cover for maternity, oncology, and chronic diseases, as well as benefits for screening and prevention.
• ➡️ Day-to-Day Benefits
• ➡️ This includes general practitioner visits, one dental exam, one eye exam, and over-the-counter medications.

Discovery Health Smart Series Benefits and Cover Comprehensive Breakdown

Emergency Cover

👉 In case of a traumatic incident or after a traumatic event, you can get help from a trained professional. Calling Emergency Assist will help you and your loved ones in need.

👉 Furthermore, family members can get help after a traumatic event at any time. The survivors of gender-based violence can receive counselling and other support as part of this service.

👉 Discovery Health Emergency Cover covers the following medical services:

• ➡️ The emergency vehicle (or other medical transport).
• ➡️ The hospital’s account of the incident.
• ➡️ The observations of the physician who admitted you to the hospital.
• ➡️ The anesthesiologist.
• ➡️ Any additional approved healthcare provider.

Prescribed Minimum Benefits

👉 All medical schemes are required by the Prescribed Minimum Benefit (PMB) provisions of the Medical Schemes Act 131 of 1998 and its Regulations to cover the costs associated with the diagnosis, treatment, and care of:

• ➡️ A life-threatening medical condition
• ➡️ A defined listing of 271 conditions
• ➡️ A list of 27 chronic illnesses.

👉 Your medical condition must be on the Prescribed Minimum Benefit (PMB) conditions list to qualify for cover. Furthermore, the necessary treatment must correspond to the remedies listed in the benefits.

👉 In addition, you are required to utilize designated service providers (DSPs) within the Discovery Health network.

👉 Once your condition has stabilized, you will be transferred to a hospital or other service providers in the Discovery Health network, if necessary, according to the scheme’s rules.

👉 Discovery Health will cover up to 80% of the Discovery Health Rate if you do not use a DSP (DHR). Your responsibility will be the difference between what Discovery Health will pay and the actual cost of your treatment.

👉 Furthermore, Discovery Health will pay according to your plan’s benefits if these criteria are unmet.

Screening and Prevention

👉 This benefit covers specific diagnostic procedures that detect early warning signs of serious diseases.

👉 The Discovery Health wellness providers cover a variety of screening tests, including blood glucose, cholesterol, HIV, Pap smear or HPV test for cervical screening, mammograms or ultrasounds, and prostate screenings.

👉 After all your membership members have completed their health check, you can access additional screening and preventive healthcare services through the WELLTH Fund.

👉 The Discovery Health Screening and Prevention covers the following:

• ➡️ Screening for kids will assess the child’s growth and development, including weight, height and body mass index measurements, blood pressure, and more.
• ➡️ Screening for Adults includes blood pressure, blood glucose, HIV, and more. Discovery also covers mammograms, breast ultrasounds, pap smears, and more.
• ➡️ Screening for Seniors (65>) includes risk screening assessments and referrals to Premier Plus GPs according to the screening results.

Additional Testing

• ➡️ Clinical eligibility requirements may apply to these tests:
• ➡️ Diabetes and cholesterol screening tests are defined.
• ➡️ Breast screening MRI or mammography and one-time BRCA testing.
• ➡️ Colonoscopy for the detection of colon cancer.
• ➡️ HPV test or Pap smear for cervical screening.
• ➡️ Vaccines (there may be clinical entry requirements):
• ➡️ Seasonal influenza vaccination for pregnant members, 65 years or older, registered with certain chronic conditions, and healthcare professionals.
• ➡️ Pneumococcal vaccination for members aged 65 or older or those registered with certain chronic conditions.
• ➡️ The WHO Global Outbreak Benefit covers the vaccines for COVID-19.

Discovery WELLTH Fund

👉 The WELLTH Fund covers a comprehensive list of screening and prevention healthcare services to empower you to act based on your individual health requirements.

👉 This benefit is distinct from and in addition to the Screening and Prevention Benefit; it is available once per lifetime to all members and dependents who have completed their health checks.

👉 Your WELLTH Fund can be used up to its maximum for screening and prevention services. However, the cover is subject to the Scheme’s clinical entry requirements, treatment protocols, and guidelines.

👉 The Discovery Health WELLTH Fund for the Smart Series covers the following:

How can members get access to the Discovery WELLTH Fund?

👉 The WELLTH Fund is available for two benefit years after all beneficiaries over two complete an age-appropriate health check with a Wellness Network provider.

👉 Furthermore, the benefit is available to new members in the joining year and subsequent years.

Which limits apply to the Discovery WELLTH Fund?

👉 The benefit is available once per lifetime per beneficiary. Cover for eligible healthcare services is limited to the Discovery Health Rate (DHR), subject to the overall benefit maximum.

👉 Your WELLTH Fund maximum is based on the size and composition of your family as stated in your policy:

• ➡️ Limited to R2,500 per adult dependent.
• ➡️ Limited to R1,250 per two-year-old or older child dependent.
• ➡️ Limited to R10,000 per family.

👉 Furthermore, the WELLTH Fund is available to all registered membership beneficiaries and will not cover healthcare services already covered by other defined benefits.

WHO Outbreak Benefit

👉 The basket of care includes the following:

• ➡️ COVID-19 vaccines and their administration according to the COVID-19 guidelines of the National Department of Health.
• ➡️ Screening consultations with a network general practitioner (virtual, telephone, or in-person).
• ➡️ COVID-19 PCR and Rapid Antigen screening tests if referred by a qualified medical practitioner.
• ➡️ A set of defined pathology tests for COVID-19-positive individuals.
• ➡️ A predetermined assortment of x-rays and scans for COVID-19-positive individuals.
• ➡️ Members at risk who meet the clinical entry criteria will receive supportive care, including medication and a home monitoring device to track oxygen saturation levels.
• ➡️ When you are admitted to the hospital because of symptoms of COVID-19, you will be covered by the Hospital Benefit of the Smart Series and, if necessary, the PMBs.
• ➡️ Access to the Long COVID Recovery Programme:
• ➡️ A six-month support programme for members whose COVID-19 symptoms persist beyond 21 days after acute diagnosis.
• ➡️ According to the Scheme’s clinical entry criteria and treatment guidelines, the programme includes the following:
• ➡️ Up to two specialists and GP consultations.
• ➡️ A defined basket of pathology tests.
• ➡️ Allied healthcare professional support.
• ➡️ A home monitoring device.
• ➡️ A defined basket of x-rays and scans.

👉 How members of the Discovery Health Smart Series are covered in terms of Monkeypox:

• ➡️ The treatment protocol for confirmed cases consists of a diagnostic PCR screening test
• ➡️ Two visits to a dermatologist or general practitioner.
• ➡️ Formulary of supportive medications for pain management.

Connected Care

👉 Discovery Health Medical Scheme provides home-based access to health and wellness services. Connected Care is an integrated ecosystem of benefits, services, and digitally connected capabilities designed to assist you in managing your health and wellness.

Connected care for members at home

👉 Previously unimaginable access to medical professionals is now at your fingertips, thanks to the advent of online consultations.

👉 Thanks to the Home Monitoring Device Benefit, you can get various approved home monitoring devices for chronic and acute conditions. You will not see any changes to your regular benefits because of having cover approved for these gadgets.

Connected care for those with chronic conditions

👉 Through Connected Care, you and your doctor can work together to keep your chronic condition under control while you are at home.

👉 Eligible members can use various digital services connected to smart remote monitoring, point-of-care devices, and individualized coaching consultations to monitor and control their chronic condition in the comfort of their homes.

Hospital At Home

👉 Hospital at Home patients receive specialized care from a dedicated medical staff in the comfort of their own homes. Each of these benefits and services contributes to your overall health and well-being. They all work together to make your healthcare more efficient and your life safer.

👉 Suppose you have a valid pre-authorization for hospitalization. In that case, Discovery Health will use your Hospital Benefit to cover any services provided as part of Discovery’s Hospital at Home programme.

👉 For those who meet the programme’s clinical and benefit criteria, this unlocks cover for approved medical devices and services.

👉 Furthermore, Discovery Health covers the following:

• ➡️ 24/7 clinical oversight from a care team virtually, including nurses, doctors, and allied healthcare professionals.
• ➡️ 24/7 real-time remote monitoring, which is supported by innovative healthcare technology.
• ➡️ Hospital-level diagnostics and intervention to manage post-surgical or medical care at home.

Acute Care at home

👉 This includes cover and treatment for COVID-19, as well as post-discharge care. In addition, you are eligible for the Home Monitoring Device Benefit.

Home Monitoring Devices

• ➡️ Suppose you meet the Scheme’s clinical entry criteria. In that case, you have healthcare cover up to a limit of R4,250 per person per year at 100% of the Discovery Health Rate (DHR) for monitoring certain conditions like chronic obstructive pulmonary disease, congestive heart failure, diabetes, pneumonia, and COVID-19.
• ➡️ If you meet the clinical entry criteria, the Scheme also covers up to 75% of the Discovery Health Rate (DHR) for defined point-of-care medical devices. You are responsible for 25% of the total cost of these devices. In addition, you have access to the most advanced remote medical examination device, known as TytoHome.
• ➡️ TytoHome enables you to conduct a medical examination by transmitting throat, ear images, and heart and lung sound to your doctor in real-time.

Home Care Cover

• ➡️ Discovery Home Care is a service that provides you with high-quality care in the comfort of your own home if your doctor recommends it as an alternative to hospitalization. Postnatal care, end-of-life care, intravenous infusions (drips), and wound care are provided. These services are covered by the Hospital Benefit, pending authorization.
• ➡️ Discovery Home Care is the designated service provider (DSP) for intravenous infusion administration. Use Discovery Home Care for these infusions to avoid a 20% co-payment.

Home-based care for follow-up treatment after hospital admission

• ➡️ Once discharged from the hospital, patients with clinically appropriate conditions such as chronic obstructive pulmonary disease, chronic cardiac failure, ischemic heart disease, and pneumonia have access to enhanced home-based care.
• ➡️ If you meet the clinical entry criteria, you are covered for bedside medicine reconciliation before admission discharge, a follow-up consultation with a GP or specialist, and a defined basket of supportive care at home, including in-person and virtual consultations with a Discovery Home Care nurse.

Day-To-Day Benefits and Cover

Discovery Maternity and Early Childhood Benefit

👉 With the Discovery Health Smart Series, you get coverage for healthcare services related to your pregnancy and treatment for the first two years of your baby’s life.

👉 This applies from the date of activation of the benefit for each pregnancy and for each child from birth until they are two years old.

👉 Discovery Health Maternity Benefit covers the following:

• ➡️ During Pregnancy:
• ➡️ Scans and Screenings
• ➡️ Eight antenatal consultations with a midwife, GP, or gynecologist.
• ➡️ 2 x 2D ultrasound scans
• ➡️ Nuchal translucency test
• ➡️ 3D and 4D scans up to the 2D scan rate.
• ➡️ Non-invasive Prenatal Test (NIPT)
• ➡️ One flu vaccination during pregnancy.
• ➡️ Discovery Health will cover predetermined blood tests to confirm your pregnancy.
• ➡️ After giving birth, Discovery Health covers the following:
• ➡️ GP and Specialist help for up to 2 years.
• ➡️ Postnatal care, including complications during delivery, nutritional assessment, etc.
• ➡️ Discovery Health prenatal and postnatal care includes:
• ➡️ Five antenatal or postnatal classes.
• ➡️ One Breastfeeding consultation.

Chronic Benefits

👉 The Chronic Disease List lists 27 conditions for which the Chronic Illness Benefit (CIB) provides cover (CDL).

Discovery Health Chronic Benefit Cover Summarized

👉 Discovery Health Smart Series Full List of conditions covered:

➡️ Addison’s disease

➡️ Asthma

➡️ Bipolar mood disorder

➡️ Bronchiectasis

➡️ Cardiac failure

➡️ Cardiomyopathy

➡️ Chronic obstructive pulmonary disease

➡️ Chronic renal disease

➡️ Coronary artery disease

➡️ Crohn’s disease

➡️ Diabetes insipidus

➡️ Diabetes Type 1

➡️ Diabetes Type 2

➡️ Dysrhythmia

➡️ Epilepsy

➡️ Glaucoma

➡️ Hemophilia

➡️ HIV

➡️ Hyperlipidemia

➡️ Hypertension

➡️ Hypothyroidism

➡️ Multiple sclerosis

➡️ Parkinson’s disease

➡️ Rheumatoid arthritis

➡️ Schizophrenia

➡️ Systemic lupus erythematosus

➡️ Ulcerative colitis

Chronic Medicine

👉 Utilize our designated service providers (DSPs), MedXpress and MedXpress Network Pharmacies, to avoid paying a 20% co-payment on your chronic medication.

👉 Through MedXpress, you can order or reorder your medication online and have it delivered to your place of business or residence. Alternatively, you can:

• ➡️ You can order your medication online and pick it up at a MedXpress Network Pharmacy or
• ➡️ Fill a prescription as usual at any pharmacy in the MedXpress Network.

Medicine Tracker

👉 You can set reminders and prompts to help you take your medication as prescribed and on time. For example, your approved chronic medication will be displayed automatically, and you will be prompted to take your medication and confirm each dose.

Discovery Care Programmes

👉 Discovery Health will cover preventative and condition-specific care programmes that assist with managing diabetes, mental health, HIV, and heart-related conditions.

👉 You must be registered with these condition-specific care programmes to access additional benefits and services. On a personalized dashboard, you and your Premier Plus GP can identify the next steps to manage your condition and maintain your health over time optimally.

👉 The cover is subject to the Scheme’s clinical entry requirements, treatment protocols, and guidelines.

Comprehensive Cancer Cover

👉 You have access to comprehensive cancer treatment coverage. This includes access to expensive medications, innovative treatments, and extended coverage once certain thresholds are reached.

Discovery Hospital Benefit

👉 The Smart Series includes hospitalization cover. Furthermore, there is no limit on the total amount covered by the Hospital Benefit.

• ➡️ If you require hospitalization, Discovery Health will cover your hospital bills.
• ➡️ There is no annual overall hospital limit on any of the plans. However, there are maximum reimbursement amounts for certain treatments.
• ➡️ Discovery Health may not cover the expenses if you do not contact the scheme before being discharged.

👉 The following table summarizes how Discovery Health pays for approved hospital admissions within the Smart Series.

Scopes

👉 You are responsible for the following amount depending on where your scope is performed. Your Hospital Benefit will cover the remaining hospital and related charges.

👉 Furthermore, the following will apply to the scopes on the Smart Series:

• ➡️ When a scope is performed outside of the Smart Day Surgery Network, a one-time payment of R11,000 is required.
• ➡️ For facilities outside of the Essential Dynamic Smart Day Surgery Network, there will be an initial payment of R13,250 required.
• ➡️ If scopes are performed in the doctor’s office as part of a confirmed Prescribed Minimum Benefits (PMB) condition or if the patient is under 12 years old, no upfront payment is required. Furthermore, the Hospital Benefit covers the bill.

Discover Annual Limits

Discovery Health Smart Cover for Day Surgery Network Procedures

👉 Discovery Health will provide cover for certain day surgery procedures. A day surgery may take place in a hospital, a day clinic, or an independent facility. Furthermore, these services are covered by your Hospital Benefit.

👉 Discovery Health will pay for hospitalization-related services, including all authorized healthcare professionals, services, and medications.

👉 If you utilize physicians, specialists, and other healthcare professionals with whom Discovery Health will have a payment arrangement, Discovery Health will cover the full cost of these services.

• ➡️ On Classic plans, Discovery Health will pay up to 200% of the Discovery Health Rate (DHR).
• ➡️ On Essential plans for other healthcare professionals, Discovery Health will pay up to 100% of the DHR.

👉 If you visit a facility that is not in your plan’s Day Surgery Network, you will be required to pay a co-payment according to the table below.

👉 The following list provides the procedures that can be performed in a Discovery Health Day Surgery Network:

➡️ Biopsies

➡️ Breast Procedures

➡️ Ear, nose, and throat procedures

➡️ Eye Procedures

➡️ Ganglionectomy

➡️ Gastrointestinal scopes and procedures

➡️ Gynecological Procedures

➡️ Orthopedic Procedures

➡️ Removal of a foreign body

➡️ Simple superficial lymphadenectomy

➡️ Skin procedures

➡️ Urological procedures

Discovery Health Smart Additional Benefits

Claims relating to Traumatic Events

➡️ Trauma Recovery Extender Benefit covers out-of-hospital trauma claims.

➡️ The Trauma Recovery Extender Benefit pays claims for the rest of the year and the year after.

➡️ For the year the trauma occurred, and the year after, you and your dependents on your health plan can receive six counseling sessions per person per year from a psychologist, clinical social worker, or registered counsellor.

➡️ To qualify, members must apply for this benefit.

Africa Evacuation Cover

➡️ Emergency medical evacuations from sub-Saharan African countries to South Africa are covered.

➡️ Excludes pre-existing conditions.

International Travel Benefit

➡️ While traveling outside South Africa, you are covered for emergency medical costs up to R5 million per person.

➡️ The cover lasts 90 days after leaving South Africa.

➡️ This benefit excludes pre-existing conditions.

➡️ Suppose the elective treatment is freely available in South Africa and covered by your plan. In that case, Discovery Health might cover it at equivalent local costs.

International Second Opinion Services

➡️ The Clinic by Cleveland Clinic provides second opinions for life-threatening and life-changing conditions through your specialist.

➡️ Discovery Health will pay 75% for second opinions.

Spinal Care Programme

➡️ Conservative spinal treatment out-of-hospital includes virtual and face-to-face consultations with an appropriately registered allied healthcare professional.

In-Room Procedures

➡️ Cover is limited to specialist room procedures.

➡️ Hospital Benefit covers up to the Scheme-authorized rate.

Advanced Illness Benefit

➡️ Members receive comprehensive palliative care.

➡️ This program covers unlimited home care, care coordination, counseling, and supportive care for appropriate end-of-life clinical and psychologist services.

➡️ Your palliative care treatment plan includes GP consultations.

Discovery Smart Series Value-Added Offers

➡️ Healthy Care at Clicks or Dis-Chem offers discounts on a wide range of personal and family care products. Healthy Care includes baby care, dental care, eye care, foot care, sun care, hand care, first aid, and over-the-counter medicine.

➡️ Your plan’s optometrists offer 20% off frames and lenses when you pay immediately.

➡️ Expectant parents can cryogenically store their newborn baby’s umbilical cord blood and tissue stem cells at a discounted rate with Netcells’ exclusive offer.

➡️ Vitality, the world’s leading science-based wellness program, rewards healthy living. As a result, Discovery Vitality members live longer and healthier lives.

➡️ Discovery Health collaborates with myHealthTeam, a global leader in online patient communities. This gives members with diabetes, heart disease, and long-term COVID access to a digital community of patients to manage their conditions.

Discovery Health Smart Series Exclusions and Waiting Periods

👉 Exclusions include the following:

• ➡️ Reconstructive surgical procedures and treatments, including cosmetic procedures and treatments.
• ➡️ Otoplasty for bat ears, blepharoplasty, and port-wine stains (eyelid surgery).
• ➡️ Breast reductions or augmentations and gynecomastia are considered cosmetic procedures.
• ➡️ Obesity
• ➡️ Unless included in Prescribed Minimum Benefits (PMBs) or Assisted Reproductive Therapy, infertility is not covered (ART) Benefit.
• ➡️ Frail care
• ➡️ Abuse of alcohol, drugs, or solvents.
• ➡️ Willful and significant infraction of the law.
• ➡️ Willful participation in a war, a terrorist act, a riot, a civil disturbance, a revolt, or an uprising.
• ➡️ Injuries incurred or medical care rendered during travel to or within a country at war.
• ➡️ Experimental, unproven, or unregistered treatments or practices.
• ➡️ Rescue and search.

👉 Additional exclusions that only apply to the Smart Series include hospitalizations caused by the following, among other things:

• ➡️ Dentistry
• ➡️ Nail disorders
• ➡️ Skin conditions, such as benign growths and lipomas
• ➡️ Investigations
• ➡️ Functional nasal surgery
• ➡️ Elective caesarean section, unless medically required
• ➡️ Hiatus hernia and esophageal reflux surgery.
• ➡️ Back and neck surgery or treatment
• ➡️ Knee and shoulder operations
• ➡️ Arthroscopy
• ➡️ Hips, knees, shoulders, and elbows are among the joints that can be replaced.
• ➡️ Cochlear implants, auditory brain implants, and internal nerve stimulators (including related procedures, devices, processors, and hearing aids) are included in this category.
• ➡️ Healthcare services provided outside of the hospital and for which hospitalization is not required.
• ➡️ Hallux valgus (bunion) and Tailor’s bunion correction (bunionette)
• ➡️ Removal of varicose veins
• ➡️ Eye correction surgery
• ➡️ Non-malignant breast disorders

👉 Discovery Health’s waiting periods are as follows:

• ➡️ During your waiting periods, you will not have access to the Prescribed Minimum Benefits (PMBs) if you are subject to waiting periods due to never having belonged to a medical scheme or a break in membership of more than 90 days before joining Discovery Health Medical Scheme, including emergency admission cover.
• ➡️ If you had less than a 90-day break in cover before enrolling in Discovery Health Medical Scheme, you might be eligible for Prescribed Minimum Benefits (PMBs) during waiting periods.

The Discovery Health Smart Series consist out of the following plans to choose from:

✅ Essential Smart Medical Aid Plan

✅ Essential Dynamic Smart Medical Aid Plan

✅ Classic Smart Medical Aid Plan