MA0268 Discovery Health KeyCare Plans Active 2011
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Transcript of MA0268 Discovery Health KeyCare Plans Active 2011
NMG Benefits 1 of 24 October 2010
Discovery Health 2011
Discovery Health changes for 2011:
Please note that a full benefit comparison of all the Discovery Health plans for 2011 is included
at the end of this letter (including contributions).
Most likely plan choice for members who were on the KeyCare plans in 2010
KeyCare Plans 2011
KeyCare Core
KeyCare Plus
Plans structure in 2011
KeyCare Core
Critical hospital care
Planned hospital care
Chronic medication
Screening Benefit
KeyFit or Vitality
KeyCare Plus
Critical hospital care
Planned hospital care
Chronic medication
Screening Benefit
Day-to-day benefits
Trauma Benefit
KeyFit or Vitality
NMG Benefits 2 of 24 October 2010
Plan details
Benefits KeyCare Plans
COVER The KeyCare Core and KeyCare Plus plans offer affordable
private health care through a selected national network of
private health care providers. The hospital benefit on both
plans offer 100% cover at the Discovery Health tariff (DH-
tariff) in a network of private hospitals.
DAY-TO-DAY BENEFITS
KeyCare Core
No benefit
KeyCare Plus
Members have access to Discovery Health’s comprehensive
network of private practitioners
No Medical Savings Account (MSA)
No Above Threshold Benefit (ATB)
Cover For specialist visits with a referral from a network GP
and an authorisation number.
Specialist limit of R2,100 per person per year
OVERALL ANNUAL LIMIT No limit
IN-HOSPITAL COVER KeyCare Core and KeyCare Plus:
100% of the DH-tariff
NMG Benefits 3 of 24 October 2010
Benefits KeyCare Plans
HOSPITALISATION
Pre-authorisation required
[at least 48 hours prior to
admission]
Paid from Hospital Benefit
LIMITS
Limits on Mental Health benefit and HIV/AIDS
Mental health benefit
Annual limit of 21 days per person on both plans
Sub-limit per person for alcohol and drug rehabilitation on
both plans
HIV/AIDS and AIDS related:
Unlimited if registered with the HIV/AIDS Management
programme
R12,000 per family if not registered with the HIV/AIDS
Management programme
EMERGENCY HOSPITALISATION
Any private hospital until stabilised, will then be transferred
to a network hospital (child birth included).
PLANNED HOSPITALISATION
Only in a network hospital Subject to approval.
Elective caesarean section not covered
TRAUMA BENEFIT Cover for day-to-day medical expenses incurred in the
same year as specified catastrophic event. Only KeyCare
Plus
INTERNAL MEDICAL
APPLIANCES
No Benefit
PRIVATE NURSING No benefit
AMBULANCE AND EMERGENCY
TRANSPORT
Limited to approval by
International SOS
Paid from Hospital Benefit
No limit
ORGAN TRANSPLANTS
Pre-authorisation required
Only covered in a State hospital
DIALYSIS
Pre-authorisation required
Only covered in a State hospital
NMG Benefits 4 of 24 October 2010
Benefits KeyCare Plans
BLOOD TRANSFUSION Only if part of an emergency operation
RADIOTHERAPY AND
CHEMOTHERAPY
Pre-authorisation required
Only covered if treated by an Oncology network
practitioner
Limited to approval of Oncology treatment plan
RADIOLOGY AND PATHOLOGY
In-hospital
Paid from Hospital Benefit
No limit
Day-to-day
Core
No benefit
Plus
Only basic x-rays and blood test on referral from network
GP.
Specialist benefit of R2,100 per person for all services
rendered by a specialist in a network hospital, subject to a
referral from a network GP and authorisation
MRI and CT SCANS
Pre-authorisation required
In-hospital
Paid from Hospital Benefit
Only if related to emergency operation.
Day-to-day
Limited to the specialist benefit limit of R2,100.
SCREENING BENEFIT Certain screening tests to be covered from Hospital Benefit
OVER THE COUNTER
MEDICATION SCHEDULE 0, 1 &
2 (even when prescribed)
No benefit
NMG Benefits 5 of 24 October 2010
Benefits KeyCare Plans
CHRONIC MEDICATION
Limited to registration with
scheme via Chronic Illness
Benefit (CIB)
Core
100% of cost from formulary or list from network provider. No
limit
Limited to registration with scheme via Chronic Illness Benefit
(CIB)
Plus
100% of cost from formulary or list from network provider. No
limit
Limited to registration with scheme via Chronic Illness Benefit
(CIB)
ACUTE MEDICATION
Preferred Provider: Medikredit
Pharmacies
Core
No benefit
Plus
100% of cost for medication on formulary or list from network
provider
OPTICAL BENEFIT Core
No benefit
Plus
One test and one pair of white mono- or bifocal glasses with
basic frame or standard contact lenses per person every
two years only at an optometrist within the KeyCare
optometry network.
SCOPES
The following procedures will be covered if done in a
KeyCare day clinic:
Colonoscopy
Gastroscopy
Sigmoidoscopy
Proctoscopy
Adenoidectomy
Myringotomy
Tonsillectomy
Cytourethroscopy
Prostate biopsy
Vasectomy
DENTAL BENEFIT Core
No benefit
Plus
Only basic dentistry covered at a network practitioner
EXTERNAL MEDICAL
APPLIANCES
Covered if part of a hospital procedure.
R3,500 per family for day-to-day appliances through a
network.
NMG Benefits 6 of 24 October 2010
Most important changes
Headline increase of 7.9%
Dentistry benefit
The single limit for dentistry no longer applies to the Comprehensive and Priority options –
Professional and facility fees for both in-and out-of-hospital are no longer subject to an overall
limit.
Related accounts (professional fees) for in-hospital dentistry will be paid from the hospital
benefit at 100% of the Discovery Health rate on Comprehensive and Priority plans – These
accounts are no longer paid from the Medical Savings Account.
The R1,975 co-payment on in-hospital dentistry will fall away and will be replaced as follows:
� R3,000 deductible for dental admissions to a normal hospital
� R2,000 deductible for dental admissions to a day-care facility.
Children under the age of 13 years will have a R1,200 deductible in hospital and a R600
deductible for day-care facilities.
There will be no deductible applicable to severe dental admissions – examples include but are
not limited to: cancer related surgery, severe trauma related surgery, cleft palate surgery.
Dental devices, appliances and orthodontics (including orthognathic surgery) will be subject
to the following limits and will be paid from the day-to-day benefits:
� R16,000 per person per year on the Comprehensive plans and R10,000 on the Priority
plans.
Benefit limits and Thresholds
Benefit limits have increased by 7.9% and Threshold levels have increased by between 7% -
10%.
Discovery Med-Xpress
This benefit allows members to contact Discovery directly to get their medication delivered to
an address of their choice. This will include monthly chronic medication orders and same-day
orders for acute medicine prescriptions.
* This benefit will be rolled out in the first quarter of 2011
NMG Benefits 7 of 24 October 2010
Oncology Care Programme
Provides additional support to members who are newly diagnosed or are living with cancer.
This benefit will include an Oncology and Medical Liaison Manager to assist the member and
their families.
Chronic Dialysis network arrangement
National Renal Care (NRC) will be the designated service provider for patients receiving
chronic dialysis on the Priority, Saver and Core plans. Newly diagnosed members who do not
utilise the NRC network will be liable for out-of-network penalties.
Integrated Care Unit
This programme will provide members who have extensive medical needs, with a holistic
treatment from a team of medical experts, care coordinators and community-based
providers. Members will receive treatment from the time they are admitted into an intensive
care unit, through discharge following rehabilitation, and into the community.
Supplementary Cancer Protector
This is a separate life policy which provides monthly expense cover, care co-ordination and a
medical savings boost in the event of any member being diagnosed with cancer, as well as a
medical scheme premium waiver benefit.
KeyFit
This benefit replaces the KeyFit offering and now offers members access to the HealthyFood™
benefit where they can receive up to 15% discount at Pick ‘n Pay stores.
45 Virgin Active gyms have been made accessible to KeyFit members for a once-off
activation fee of R295 with a 67% saving on the monthly gym fee. Adults and children over the
age of 18 years will save 50% on the monthly gym fee. Members have the option of
enhancing their KeyFit benefits by doing the Vitality Checks.
Vitality
Emirates has been introduced as a new international travel partner in addition to British
Airways.
NMG Benefits 8 of 24 October 2010
Information sessions
We would strongly advise members attend one of the information sessions.
Date Time
09h00 – 11h00 11h00 – 13h00 14h00 – 16h00
Monday
25 Oct 2010
Auditorium, JS Gericke
Library
Auditorium, JS Gericke
Library
Auditorium, JS
Gericke Library
Wednesday
27 Oct 2010
Auditorium, JS Gericke
Library
Pensioners
Auditorium, JS Gericke
Library
English
Auditorium, JS
Gericke Library
Thursday
28 Oct 2010
Auditorium, JS Gericke
Library
Auditorium, JS Gericke
Library
Auditorium, JS
Gericke Library
Friday
29 Oct 2010
Tygerberg Campus
Lecture Hall 8
Teaching Wing
Bellvillepark Campus
Room 103
Van Der Horst Building
Tuesday
2 Nov 2010
Auditorium, JS Gericke
Library
Pensioners
Auditorium, JS Gericke
Library
Auditorium, JS
Gericke Library
Plan changes for 2011
Members who wish to make a plan change for 2011, will be given the opportunity to make
these changes online via the Human Resources link on the University's website. Members will
be able to make these changes online from Monday 25 October 2010 to Tuesday 30
November 2010 at 14h30.
Members who do not have access to a computer and/or the website, have to contact the
Human Resources Customer Services Desk for assistance.
HOW TO CHANGE YOUR PLAN FOR 2011 ON THE WEBSITE
- Visit the US webpage at http://www.sun.ac.za
- Click ‘For Personnel’
- Enter your ‘Username and Password’
- Choose ‘SUN-e-HR’
- Enter your ‘Username and Password’
- Click on ‘SUN Employee Self Service’
- At ‘External Links’ choose ‘Medical Aid Choice 2011’
- Click on “Choose Medical Aid for 01 Jan 2011”
- You will only be allowed to structure your medical scheme plan
NMG Benefits 9 of 24 October 2010
CHOOSE YOUR PLAN FOR 2011 NOW
- The option to choose your plan will be under Struktureringsvoordele / Structuring Benefits
- When clicking on the down arrow v all the plan options will appear. Click on your chosen
plan for 2011
- Choose Vitality or KeyFit or Vitality & KeyFit (both)
- Once you have made your choice, your MSA and Threshold (if applicable) will
automatically appear.
Confirm your choice by clicking on Save Package
Once you have clicked on Save Package you will receive and e-mail confirming the plan
choice that you have made for 2011. If you do not receive an e-mail it means that your
plan choice has not been stored and package structuring and we then request that you
send an urgent e-mail to [email protected] confirming your plan choice for 2011.
The closing date for plan choices is 30 November 2010 and not any other date that you may
see on any of Discovery Health’s communications.
Enquiries
Should you have any queries regarding your plan choice for 2011, please contact Chantel
Smith at the SU campus satellite office:
Date and times Contact details Address
Monday, Tuesday and
Thursday
08h00 to 16h30
Tel: (021) 808 4827 or
Stellenbosch Campus Admin
building
Block C
Room C1322
Wednesday
08h00 to 13h00
Tel: (021) 938 9013 or
Tygerberg Campus
Admin building
Room 1061
Friday
08h00 to 16h30
Tel: (021) 447 6147 or
NMG Cape Town
Black River Park
Observatory
Should you have any problematic queries regarding your claims, membership, chronic
benefits or general administration, please contact your Discovery Health call centre on:
Share Call: 0860 10 30 80
Website: www.discovery.co.za
NMG Benefits 10 of 24 October 2010
General
Please note that NMG has made every effort to ensure that the information provided in this
newsletter is correct, but that this is merely a summary of the benefits and in the event of a
dispute, the Rules of Discovery Health will prevail.
From 25 October 2010, detailed information regarding all the Discovery Health Plans for 2011
will be available on the SU’s homepage.
(Keycare Plans – Active 2010)
Discovery Health Benefit Comparison 2011
NMG Benefits 11 of 24 E&OE October 2010
Benefits KeyCare Plans Core Plans Saver Plans Priority Plans Comprehensive Plans Executive Plan
COVER The KeyCare Core
and KeyCare Plus
plans offer affordable
private health care
through a selected
national network of
private health care
providers. The hospital
benefit on both plans
offer 100% cover at
the Discovery Health
tariff (DH-tariff) in a
network of private
hospitals.
The Classic, Essential,
Coastal, Classic Delta
and Essential Delta
Core Plans offer
comprehensive in-
hospital benefits.
The Delta plans offer
in-hospital cover
through a network of
private hospitals
The Classic, Essential,
Coastal, Classic Delta
and Essential Delta
Saver Plans offer
comprehensive in-
hospital cover and
basic day-to-day
cover through a
Medical Savings
Account.
The Delta plans offer
in-hospital cover
through a network of
private hospitals
The Classic and
Essential Priority Plans
offer cost effective in-
and out-of hospital
cover. A defined co-
payment is payable
on specified in-
hospital
planned/elective
procedures.
The Classic, Essential,
Classic Delta and
Essential Delta
Comprehensive Plans
offer comprehensive
in-and out-of hospital
cover.
The Delta plans offer
in-hospital cover
through a network of
private hospitals
The Executive Plan
offers the most
comprehensive in-and
day-to-day cover of
all the Discovery
Health Plans
Discovery Health Benefit Comparison 2011
NMG Benefits 12 of 24 E&OE October 2010
Benefits KeyCare Plans Core Plans Saver Plans Priority Plans Comprehensive Plans Executive Plan
DAY-TO-DAY BENEFITS
KeyCare Core
No benefit
KeyCare Plus
Members have
access to Discovery
Health’s
comprehensive
network of private
practitioners
No Medical Savings
Account (MSA)
No Above Threshold
Benefit (ATB)
Cover For specialist
visits with a referral
from a network GP
and an authorisation
number.
Specialist limit of
R2,100 per person per
year
No day-to-day
benefits
No Medical Savings
Account (MSA)
No Above Threshold
Benefit (ATB)
Medical Savings
Account (MSA)
Day-to-day benefits
are paid from the
MSA and ATB
MSA value
Classic Saver: 25%
Essential Saver: 15%
Coastal Saver: 25%
Classic Delta: 25%
Essential Delta: 15%
Any remaining savings
will role-over from one
year to the next.
No Above Threshold
Benefit (ATB)
Insured Network
Benefit
Members on Saver
plans have defined
cover for network GP
visits once their MSA is
exhausted.
Classic and Coastal
Saver
Single member: 3 visits
Family: 6 visits
Essential Saver
Single member: 2 visits
Family: 4 visits
Medical Savings
Account (MSA)
Day-to-day benefits
are paid from the
MSA and ATB
MSA value
Classic Priority: 25%
Essential Priority: 15%
Any remaining savings
will role-over from one
year to the next.
Above Threshold
Benefit (ATB)
The ATB offers cover
for day-to-day
expenses as soon as a
threshold level has
been reached:
Principal member:
R7,450
Spouse/Adult: R5,600
Per child: R2,450
(Maximum of three
children)
Overall ATB limit
Principal member:
R6,350
Spouse/Adult: R4,500
Per child: R2,200
(Maximum of three
children)
Insured Network
Benefit
Network GP visits and
Pathology tests paid
from Hospital benefits
when in the Self
Payment Gap and
ATB.
Medical Savings
Account (MSA)
Day-to-day benefits
are paid from the
MSA and ATB
MSA value
Classic Comp: 25%
Essential Comp:15%
Classic Delta Comp:
25%
Essential Delta Comp:
15%
Any remaining savings
will role-over from one
year to the next.
Above Threshold
Benefit (ATB)
The ATB offers cover
for day-to-day
expenses as soon as a
threshold level has
been reached:
Principal member:
R8,450
Spouse/Adult: R8,450
Per child: R1,600
(Maximum of three
children)
Insured Network
Benefit
Network GP visits and
Pathology tests paid
from Hospital benefits
when in the Self
Payment Gap and
ATB.
Medical Savings
Account (MSA)
Day-to-day benefits
are paid from the MSA
and ATB
MSA value
Executive : 25%
Any remaining savings
will role-over from one
year to the next.
Above Threshold
Benefit (ATB)
The ATB offers cover
for day-to-day
expenses as soon as a
threshold level has
been reached:
Principal member:
R9,260
Spouse/Adult: R9,260
Per child: R1,750
(Maximum of three
children)
Insured Network
Benefit
Network GP visits and
Pathology tests paid
from Hospital benefits
when in the Self
Payment Gap and
ATB.
OVERALL ANNUAL
LIMIT
No limit
No limit
No limit No limit No limit
No limit
Discovery Health Benefit Comparison 2011
NMG Benefits 13 of 24 E&OE October 2010
Benefits KeyCare Plans Core Plans Saver Plans Priority Plans Comprehensive Plans Executive Plan
IN-HOSPITAL COVER KeyCare Core and
KeyCare Plus:
100% of the DH-tariff
Classic: 200% of DH-
tariff
Coastal: 100% of DH-
tariff
Essential: 100% of DH-
tariff
Classic Delta: 200% of
DH-tariff
Essential Delta: 100%
of DH-tariff
Classic: 200% of DH-
tariff
Coastal: 100% of DH-
tariff
Essential: 100% of DH-
tariff
Classic Delta: 200% of
DH- tariff
Essential Delta: 100%
of DH-tariff
Classic: 200% of DH-
tariff
Essential: 100% of DH-
tariff
Classic: 200% of DH-
tariff
Essential: 100% of DH-
tariff
Classic Delta: 200% of
DH-tariff
Essential Delta: 100%
of DH-tariff
Executive: 300% of
DH-tariff
Discovery Health Benefit Comparison 2011
NMG Benefits 14 of 24 E&OE October 2010
Benefits KeyCare Plans Core Plans Saver Plans Priority Plans Comprehensive Plans Executive Plan
HOSPITALISATION
Pre-authorisation
required
[at least 48 hours prior
to admission]
Paid from Hospital
Benefit
LIMITS
Limits on Mental
Health benefit and
HIV/AIDS
Mental health benefit
Annual limit of 21 days
per person on both
plans
Sub-limit per person
for alcohol and drug
rehabilitation on both
plans
HIV/AIDS and AIDS
related:
Unlimited if registered
with the HIV/AIDS
Management
programme
R12,000 per family if
not registered with the
HIV/AIDS
Management
programme
EMERGENCY
HOSPITALISATION
Any private hospital
until stabilised, will
then be transferred to
a network hospital
(child birth included).
PLANNED
HOSPITALISATION
Only in a network
hospital Subject to
approval.
Elective caesarean
section not covered
Paid from Hospital
Benefit
LIMITS
Limits on Mental
Health benefit and
HIV/AIDS
Mental health benefit
Limited to 21 days on
all plans
Sub-limit per person
for alcohol and drug
rehabilitation
HIV/AIDS and AIDS
related:
R35,000 per family if
not registered on the
HIV/AIDS
Management
Programme. Unlimited
if registered on the
HIV/AIDS
Management
Programme
Co-Payments
Coastal
a 30% Co-payment
will be payable on the
hospital account if a
planned or elective
hospital procedure is
not performed in a
Coastal network
hospital
Delta
a R4,150 co-payment
will be payable on the
hospital account if a
planned or elective
hospital procedure is
not performed in a
network hospital
Paid from Hospital
Benefit
LIMITS
Limits on Mental
Health benefit and
HIV/AIDS
Mental health benefit
Limited to 21 days on
all plans
Sub-limit per person
for alcohol and drug
rehabilitation
HIV/AIDS and AIDS
related:
R35,000 per family if
not registered on the
HIV/AIDS
Management
Programme. Unlimited
if registered on the
HIV/AIDS
Management
Programme
Co-payments
Coastal
a 30% Co-payment
will be payable on the
hospital account if a
planned or elective
hospital procedure is
not performed in a
Coastal network
hospital
Delta
a R4,150 co-payment
will be payable on the
hospital account if a
planned or elective
hospital procedure is
not performed in a
network hospital
Paid from Hospital
Benefit
LIMITS
Limits on Mental
Health benefit and
HIV/AIDS
Mental health benefit
Limited to 21 days on
all plans
Sub-limit per person
for alcohol and drug
rehabilitation on both
plans
HIV/AIDS and AIDS
related:
R35,000 per family if
not registered on the
HIV/AIDS
Management
Programme. Unlimited
if registered on the
HIV/AIDS
Management
Programme
Defined deductibles
Classic and Essential
Priority:
List of defined
procedures that
require a defined
deductible that can
range from R1,600 to
R7,900
Paid from Hospital
Benefit
LIMITS
Limits on Mental
Health benefit and
HIV/AIDS
Mental health benefit
Limited to 21 days
Sub-limit per person
for alcohol and drug
rehabilitation
HIV/AIDS and AIDS
related:
R35,000 per family if
not registered on the
HIV/AIDS
Management
Programme. Unlimited
if registered on the
HIV/AIDS
Management
Programme
Delta
a R4,150 co-payment
will be payable on the
hospital account if a
planned or elective
hospital procedure is
not performed in a
network hospital
Paid from Hospital
Benefit
LIMITS
Limits on Mental
Health benefit and
HIV/AIDS
Mental health benefit
Limited to 21 days
Sub-limit per person
for alcohol and drug
rehabilitation
HIV/AIDS and AIDS
related:
R35,000 per family if
not registered on the
HIV/AIDS
Management
Programme. Unlimited
if registered on the
HIV/AIDS
Management
Programme
Discovery Health Benefit Comparison 2011
NMG Benefits 15 of 24 E&OE October 2010
Benefits KeyCare Plans Core Plans Saver Plans Priority Plans Comprehensive Plans Executive Plan
TRAUMA BENEFIT Cover for day-to-day
medical expenses
incurred in the same
year as specified
catastrophic event.
Only KeyCare Plus
No Benefit Cover for day-to-day
medical expenses
incurred in the same
year as specified
catastrophic event.
Cover for day-to-day
medical expenses
incurred in the same
year as specified
catastrophic event.
Cover for day-to-day
medical expenses
incurred in the same
year as specified
catastrophic event.
Cover for day-to-day
medical expenses
incurred in the same
year as specified
catastrophic event.
INTERNAL MEDICAL
APPLIANCES
No Benefit Paid from Hospital
Benefit
Sub-limits:
Cochlear implants
and auditory brain
implants: R133,000 per
person per benefit
Internal nerve
stimulators: R101,000
per person
Hip, shoulder and
knee joint prostheses:
R31,500 per person
per prostheses
Spinal surgery
prostheses: R21,000
per person for each
level (limits apply)
Paid from Hospital
Benefit
Sub-limits:
Cochlear implants
and auditory brain
implants: R133,000 per
person per benefit
Internal nerve
stimulators: R101,000
per person
Hip, shoulder and
knee joint prostheses:
R31,500 per person
per prostheses
Spinal surgery
prostheses: R21,000
per person for each
level (limits apply)
Paid from Hospital
Benefit
Sub-limits:
Cochlear implants
and auditory brain
implants: R133,000 per
person per benefit
Internal nerve
stimulators: R101,000
per person
Hip, shoulder and
knee joint prostheses:
R31,500 per person
per prostheses
Spinal surgery
prostheses: R21,000
per person for each
level (limits apply)
Paid from Hospital
Benefit
Sub-limits:
Cochlear implants
and auditory brain
implants: R133,000 per
person per benefit
Internal nerve
stimulators: R101,000
per person
Hip , shoulder and
knee joint prostheses:
R31,500 per person
per prostheses
Spinal surgery
prostheses: R21,000
per person for each
level (limits apply)
Paid from Hospital
Benefit
Sub-limits:
Cochlear implants
and auditory brain
implants: R133,000 per
person per benefit
Internal nerve
stimulators: R101,000
per person
Hip , shoulder and
knee joint prostheses:
R31,500 per person
per prostheses
Spinal surgery
prostheses:
R21,000 per person for
each level (limits
apply)
PRIVATE NURSING No benefit No benefit Paid at 100% of the
DH-tariff and limited to
funds in MSA
Paid at 100% of the
DH-tariff from MSA
and ATB.
Limit: (applicable to
MSA and ATB) R6,650
per family
Paid at 100% of the
DH-tariff from MSA
and ATB.
Limit: (applicable to
MSA and ATB) R6,650
per family
Paid at 100% of the
DH-tariff from MSA
and ATB.
Limit: (applicable to
MSA and ATB) R6,650
per family
AMBULANCE AND
EMERGENCY
TRANSPORT
Limited to approval by
International SOS
Paid from Hospital
Benefit
No limit
Paid from Hospital
Benefit
No limits
Paid from Hospital
Benefit
No limit
Paid from Hospital
Benefit
No limit
Paid from Hospital
Benefit
No limit
Paid from Hospital
Benefit
No limit
ORGAN TRANSPLANTS
Pre-authorisation
required
Only covered in a
State hospital
Paid from Hospital
Benefit
No limit
Harvesting of donor
organs not covered
Paid from Hospital
Benefit
No limit
Harvesting of donor
organs not covered
Paid from Hospital
Benefit
No limit
Harvesting of donor
organs not covered
Paid from Hospital
Benefit
No limit
Harvesting of donor
organs not covered
Paid from Hospital
Benefit
No limit
Harvesting of donor
organs not covered
Discovery Health Benefit Comparison 2011
NMG Benefits 16 of 24 E&OE October 2010
Benefits KeyCare Plans Core Plans Saver Plans Priority Plans Comprehensive Plans Executive Plan
DIALYSIS
Pre-authorisation
required
Only covered in a
State hospital
Paid from Hospital
Benefit
No limit
Day-to-day medicine
covered via the
Chronic Illness Benefit
Paid from Hospital
Benefit
No limit
Day-to-day medicine
covered via the
Chronic Illness Benefit
Paid from Hospital
Benefit
No limit
Day-to-day medicine
covered via the
Chronic Illness Benefit
Paid from Hospital
Benefit
No limit
Day-to-day medicine
covered via the
Chronic Illness Benefit
Paid from Hospital
Benefit
No limit
Day-to-day medicine
covered via the
Chronic Illness Benefit
BLOOD TRANSFUSION Only if part of an
emergency operation
Paid from Hospital
Benefit
No limit
Paid from Hospital
Benefit
No limit
Paid from Hospital
Benefit
No limit
Paid from Hospital
Benefit
No limit
Paid from Hospital
Benefit
No limit
RADIOTHERAPY AND
CHEMOTHERAPY
Pre-authorisation
required
Only covered if
treated by an
Oncology network
practitioner
Limited to approval of
Oncology treatment
plan
In-hospital
Paid from Hospital
Benefit
The first R200,000 of
approved treatment
in a 12 months cycle
will be covered in full
without any co-
payments. Thereafter
there will be a 20% co-
payment for every
additional Rand
without any limit.
Day-to-day
No benefit for blood
tests, consultations
and related
medication
Subject to approval of
Oncology treatment
plan
In-hospital
Paid from Hospital
Benefit
The first R200,000 of
approved treatment
in a 12 months cycle
will be covered in full
without any co-
payments. Thereafter
there will be a 20% co-
payment for every
additional Rand
without any limit.
Day-to-day
Blood tests,
consultations and
related medication
paid from MSA
Subject to approval of
Oncology treatment
plan
In-hospital
Paid from Hospital
Benefit
The first R200,000 of
approved treatment
in a 12 months cycle
will be covered in full
without any co-
payments. Thereafter
there will be a 20% co-
payment for every
additional Rand
without any limit.
Day-to-day
Blood tests,
consultations and
related medication
paid from MSA or ATB
Overall ATB limit
Principal member:
R6,350
Spouse/Adult: R4,500
Per child: R2,200
(Maximum of three
children)
Subject to approval of
Oncology treatment
plan
In-hospital
Paid from Hospital
Benefit
The first R400,000 of
approved treatment
in a 12 months cycle
will be covered in full
without any co-
payments. Thereafter
there will be a 20% co-
payment for every
additional Rand
without any limit.
Day-to-day
Blood tests,
consultations and
related medication
paid from MSA and
ATB
Subject to approval of
Oncology treatment
plan
In-hospital
Paid from Hospital
Benefit
The first R400,000 of
approved treatment
in a 12 months cycle
will be covered in full
without any co-
payments. Thereafter
there will be a 20% co-
payment for every
additional Rand
without any limit.
Day-to-day
Blood tests,
consultations and
related medication
paid from MSA and
ATB
Subject to approval of
Oncology treatment
plan
Discovery Health Benefit Comparison 2011
NMG Benefits 17 of 24 E&OE October 2010
Benefits KeyCare Plans Core Plans Saver Plans Priority Plans Comprehensive Plans Executive Plan
RADIOLOGY AND
PATHOLOGY
In-hospital
Paid from Hospital
Benefit
No limit
Day-to-day
Core
No benefit
Plus
Only basic x-rays and
blood test on referral
from network GP.
Specialist benefit of
R2,100 per person for
all services rendered
by a specialist in a
network hospital,
subject to a referral
from a network GP
and authorisation
In-hospital
Paid from Hospital
Benefit
No limit
Day-to-day
No benefit
In-hospital
Paid from Hospital
Benefit
No limit
Day-to-day
100% of DH-tariff paid
from MSA
In-hospital
Paid from Hospital
Benefit
No limit
Day-to-day
100% of DH-tariff paid
from MSA or ATB
Overall ATB limit
Principal member:
R6,350
Spouse/Adult: R4,500
Per child: R2,200
(Maximum of three
children)
In-hospital
Paid from Hospital
Benefit
No limit
Day-to-day
100% of DH-tariff paid
from MSA and ATB
In-hospital
Paid from Hospital
Benefit
No limit
Day-to-day
100% of DH-tariff paid
from MSA and ATB
Discovery Health Benefit Comparison 2011
NMG Benefits 18 of 24 E&OE October 2010
Benefits KeyCare Plans Core Plans Saver Plans Priority Plans Comprehensive Plans Executive Plan
MRI and CT SCANS
Pre-authorisation
required
In-hospital
Paid from Hospital
Benefit
Only if related to
emergency
operation.
Day-to-day
Limited to the
specialist benefit limit
of R2,100.
In-hospital
Paid from Hospital
Benefit
Subject to referral by
a specialist
No benefit for MRI or
CT scans done when
the member is
admitted to hospital
for conservative back
treatment.
Day-to-day
No benefit
In-hospital
Paid from Hospital
Benefit
Subject to referral by
a specialist
For in-hospital
conservative back
treatment the first
R2,100 of the MRI/CT
scan will be paid from
MSA and the balance
of the hospital
account and the
related accounts will
be paid from the
Hospital Benefit.
Day-to-day
First R2,100 of MRI and
CT scan paid from
MSA
In-hospital
Paid from Hospital
Benefit
Subject to referral by
a specialist
For in-hospital
conservative back
treatment the first
R2,100 of the MRI/CT
scan will be paid from
MSA/ATB and the
balance of the
hospital account and
the related accounts
will be paid from the
Hospital Benefit.
Day-to-day
First R2,100 of MRI and
CT paid from MSA and
ATB. The balance of
the account will be
paid from the Hospital
Benefit.
Overall ATB limit
Principal member:
R6,350
Spouse/Adult: R4,500
Per child: R2,200
(Maximum of three
children)
In-hospital
Paid from Hospital
Benefit
Subject to referral by
a specialist
For in-hospital
conservative back
treatment the first
R2,100 of the MRI/CT
scan will be paid from
MSA/ATB and the
balance of the
hospital account and
the related accounts
will be paid from the
Hospital Benefit.
Day-to-day
First R2,100 of MRI and
CT paid from MSA and
ATB. The balance of
the account will be
paid from the Hospital
Benefit.
In-hospital
Paid from Hospital
Benefit
Subject to referral by
a specialist
Day-to-day
Paid from the MSA
and or ATB
SCREENING BENEFIT Certain screening
tests to be covered
from Hospital Benefit
Certain screening
tests to be covered
from Hospital Benefit
Certain screening
tests to be covered
from Hospital Benefit
Certain screening
tests to be covered
from Hospital Benefit
Certain screening
tests to be covered
from Hospital Benefit
Certain screening
tests to be covered
from Hospital Benefit
Discovery Health Benefit Comparison 2011
NMG Benefits 19 of 24 E&OE October 2010
Benefits KeyCare Plans Core Plans Saver Plans Priority Plans Comprehensive Plans Executive Plan
OVER THE COUNTER
MEDICATION
SCHEDULE 0, 1 & 2
(even when
prescribed)
No benefit No benefit
Limited to funds in
MSA
Up to a maximum of
75% of the DH-tariff for
non-generic medicine
Up to a maximum of
100% of the DH-tariff
for generic medicine
Limited to funds in
MSA
Up to a maximum of
75% of the DH-tariff for
non-generic medicine
Up to a maximum of
100% of the DH-tariff
for generic medicine
[Does not accumulate
to the ATB and will not
be covered once in
ATB]
Limited to funds in
MSA
Up to a maximum of
75% of the DH-tariff for
non-generic medicine
Up to a maximum of
100% of the DH-tariff
for generic medicine.
[Does not accumulate
to the ATB and will not
be covered once in
ATB]
Limited to funds in
MSA
Up to a maximum of
90% of the DH-tariff for
non-generic medicine
Up to a maximum of
100% of the DH-tariff
for generic medicine.
[Does not accumulate
to the ATB and will not
be covered once in
ATB]
CHRONIC
MEDICATION
Limited to registration
with scheme via
Chronic Illness Benefit
(CIB)
Core
100% of cost from
formulary or list from
network provider. No
limit
Limited to registration
with scheme via
Chronic Illness Benefit
(CIB)
Plus
100% of cost from
formulary or list from
network provider. No
limit
Limited to registration
with scheme via
Chronic Illness Benefit
(CIB)
26 Prescribed
Minimum Benefits
(PMB) conditions and
HIV/AIDS
Cover for 26 listed
conditions Limited to
a formulary or Class
Drug Amount
Other chronic
conditions
No benefit
26 Prescribed
Minimum Benefits
(PMB) conditions and
HIV/AIDS
Cover for 26 listed
conditions Limited to
a formulary or Class
Drug Amount
Other chronic
conditions
Limited to funds in
MSA
26 Prescribed
Minimum Benefit
(PMB) chronic
conditions and
HIV/AIDS
Cover for 26 listed
conditions Limited to
a formulary or Class
Drug Amount
Other chronic
conditions
Conditions not
covered by the CIB
will be paid from MSA
or ATB
26 Prescribed
Minimum Benefit
(PMB) chronic
conditions and
HIV/AIDS
100% of DH-tariff from
Hospital Benefit for
approved
medication.
Limited to a drug
formulary or Class
Drug Amount
More than 30
additional chronic
conditions
Paid from Hospital
Benefit
Limited to a drug
formulary or Class
Drug Amount
Other chronic
conditions
Conditions not
covered by the CIB
will be paid from MSA,
then ATB Limited to
acute medication
limit
26 Prescribed
Minimum Benefit
(PMB) conditions and
HIV/AIDS
100% of DH-tariff from
Hospital Benefit for
approved
medication.
Limited to a drug
formulary or Class
Drug Amount
More than 30
additional chronic
conditions
Paid from Hospital
Benefit
Limited to a drug
formulary or Class
Drug Amount
Other chronic
conditions
Paid from MSA, then
ATB Limited to acute
medication limit
Discovery Health Benefit Comparison 2011
NMG Benefits 20 of 24 E&OE October 2010
Benefits KeyCare Plans Core Plans Saver Plans Priority Plans Comprehensive Plans Executive Plan
ACUTE MEDICATION
Preferred Provider:
Medikredit
Pharmacies
Core
No benefit
Plus
100% of cost for
medication on
formulary or list from
network provider
No benefit
Limited to funds in
MSA
Up to a maximum of
75% of the DH-tariff for
non-generic medicine
Up to a maximum of
100% of the DH-tariff
for generic medicine
Limited to funds in
MSA or ATB
Up to a maximum of
75% of the DH-tariff for
non-generic medicine
Up to a maximum of
100% of the DH-tariff
for generic medicine
Overall ATB limit
Principal member:
R6,350
Spouse/Adult: R4,500
Per child: R2,200
(Maximum of three
children)
Paid from MSA and
ATB
Up to a maximum of
75% of the DH-tariff for
non-generic medicine
Up to a maximum of
100% of the DH-tariff
for generic medicine.
Limit (from MSA and
ATB):
Classic and Classic
Delta
Single member:
R16,900
Member + 1: R19,850
Member + 2: R23,050
Member + 3: R26,300
Essential and Essential
Delta
Single member:
R10,950
Member + 1: R13,250
Member + 2: R15,950
Member + 3: R17,450
Paid from MSA and
ATB
Up to a maximum of
90% of the DH-tariff for
non-generic medicine
Up to a maximum of
100% of the DH-tariff
for generic medicine.
Limit (from MSA and
ATB):
Single member:
R20,800
Member + 1: R24,300
Member + 2: R27,850
Member + 3: R31,400
OPTICAL BENEFIT Core
No benefit
Plus
One test and one pair
of white mono- or
bifocal glasses with
basic frame or
standard contact
lenses per person
every two years only
at an optometrist
within the KeyCare
optometry network.
No benefit
Limited to funds in
MSA
100% of the DH-tariff
paid from MSA or ATB
Limit (from MSA and
ATB): R2,600 per
person
Overall ATB limit
Principal member:
R6,350
Spouse/Adult: R4,500
Per child: R2,200
(Maximum of three
children)
100% of the DH-tariff
paid from MSA and
ATB.
Limit (from MSA and
ATB): R2,800 per
person
100% of the DH-tariff
paid from MSA or ATB.
Limit (from MSA and
ATB): R4,100 per
person
Discovery Health Benefit Comparison 2011
NMG Benefits 21 of 24 E&OE October 2010
Benefits KeyCare Plans Core Plans Saver Plans Priority Plans Comprehensive Plans Executive Plan
SCOPES
The following
procedures will be
covered if done in a
KeyCare day clinic:
Colonoscopy
Gastroscopy
Sigmoidoscopy
Proctoscopy
Adenoidectomy
Myringotomy
Tonsillectomy
Cytourethroscopy
Prostate biopsy
Vasectomy
In-hospital
The first R2,375 of the
hospital account is
paid by the member.
The balance of the
hospital account is
paid from the hospital
benefit as well as the
related accounts.
In the Dr’s rooms
No benefit
In-hospital
The first R2,375 of the
hospital account is
paid from the MSA.
The balance of the
hospital account is
paid from the hospital
benefit as well as the
related accounts.
In the Dr’s rooms
Paid from the hospital
benefit
In-hospital
The hospital account
will attract a
deductible
depending on the
scope. The balance of
the hospital account
and related accounts
are paid from the
hospital benefit.
In the Dr’s rooms
Paid from the hospital
benefit
In-hospital
The first R1,900 of
hospital account will
be paid from MSA
and ATB. The balance
of the hospital
account as well as the
related accounts will
be paid from the
hospital benefit.
In the Dr’s rooms
Paid from the hospital
benefit
In-hospital
The hospital account
will be aid from the
Hospital Benefit and
all related accounts
will be paid from MSA
and ATB
In the Dr’s rooms
Paid from MSA and
ATB
Discovery Health Benefit Comparison 2011
NMG Benefits 22 of 24 E&OE October 2010
Benefits KeyCare Plans Core Plans Saver Plans Priority Plans Comprehensive Plans Executive Plan
DENTAL BENEFIT Core
No benefit
Plus
Only basic dentistry
covered at a network
practitioner
In-hospital and in a
day clinic
The hospital and day
clinic account will be
paid from the hospital
benefit, subject to a
deductible:
Hospital
Deductible payable if
the patient is older
than 13 years: R3,000
Deductible if the
patient is younger
than 13 years: R1,200
Day clinic
Deductible payable if
the patient is older
than 13 years: R2,000
Deductible if the
patient is younger
than 13 years: R600
All related accounts
for the dental
procedure in-hospital
and day clinic will be
paid from the hospital
benefit at 100% of the
DH-tariff.
No benefit for day-to-
day dentistry
No benefit for dental
devices and
appliances
In-hospital and in a
day clinic
The hospital and day
clinic account will be
paid from the hospital
benefit, subject to a
deductible:
Hospital
Deductible payable if
the patient is older
than 13 years: R3,000
Deductible if the
patient is younger
than 13 years: R1,200
Day clinic
Deductible payable if
the patient is older
than 13 years: R2,000
Deductible if the
patient is younger
than 13 years: R600
All related accounts
for the dental
procedure in-hospital
and day clinic will be
paid from the hospital
benefit at 100% of the
DH-tariff.
Day-to-day dentistry
paid from MSA
Dental devices and
appliances paid from
MSA
In-hospital and in a
day clinic
The hospital and day
clinic account will be
paid from the hospital
benefit, subject to a
deductible:
Hospital
Deductible payable if
the patient is older
than 13 years: R3,000
Deductible if the
patient is younger
than 13 years: R1,200
Day clinic
Deductible payable if
the patient is older
than 13 years: R2,000
Deductible if the
patient is younger
than 13 years: R600
All related accounts
for the dental
procedure in-hospital
and day clinic will be
paid from the hospital
benefit at 100% of the
DH-tariff.
Day-to-day dentistry
paid from MSA and
ATB
Limit of R10,000 for
dental devices and
appliances, limited to
MSA and ATB
Overall ATB limit
Principal member:
R6,350
Spouse/Adult: R4,500
Per child: R2,200
(Maximum of three
children)
In-hospital and in a
day clinic
The hospital and day
clinic account will be
paid from the hospital
benefit, subject to a
deductible:
Hospital
Deductible payable if
the patient is older
than 13 years: R3,000
Deductible if the
patient is younger
than 13 years: R1,200
Day clinic
Deductible payable if
the patient is older
than 13 years: R2,000
Deductible if the
patient is younger
than 13 years: R600
All related accounts
for the dental
procedure in-hospital
and day clinic will be
paid from the hospital
benefit at 100% of the
DH-tariff.
Day-to-day dentistry
paid from MSA and
ATB
Limit of R16,000 for
dental devices and
appliances, limited to
MSA and ATB
In-hospital
Hospital account is
paid from Hospital
Benefit. Related
accounts for in-
hospital dentistry, eg
dentists and
anaesthetists, paid
from MSA and ATB.
Day-to-day
Paid from MSA and
ATB, subject to benefit
limit
Limit (from MSA and
ATB):
R26,000 per person
Discovery Health Benefit Comparison 2011
NMG Benefits 23 of 24 E&OE October 2010
Benefits KeyCare Plans Core Plans Saver Plans Priority Plans Comprehensive Plans Executive Plan
EXTERNAL MEDICAL
APPLIANCES
Covered if part of a
hospital procedure.
R3,500 per family for
day-to-day
appliances through a
network.
No benefit
Limited to funds in
MSA
Paid from MSA or ATB
Overall ATB limit
Principal member:
R6,350
Spouse/Adult dep:
R4,500
Per child: R2,200
(Maximum of three
children)
Paid from MSA and
ATB, subject to benefit
limit
Limits (from MSA and
ATB)
Classic and Classic
Delta
R43,250 per family,
including hearing-aid
sub-limit of R15,800
Essential and Essential
Delta
R28,750 per family,
including hearing-aid
sub-limit of R12,800
Paid first from MSA
and ATB, subject to
benefit limit
Limits (from MSA and
ATB)
R43,250 per family,
including hearing-aid
sub-limit R15,800
Discovery Health Contribution table 2011
NMG Benefits 24 of 24 October 2010
Scheme Plan Member
Spouse/Adult
dependant Child
Discovery
KeyCare Core (R0 to R6,250) R427 R427 R107
KeyCare Core (R6,251 to R8,300) R531 R531 R133
KeyCare Core (R8,301+) R821 R821 R185
KeyCare Plus (R0 to R3,900) R445 R445 R119
KeyCare Plus (R3,901 to R6,250) R533 R533 R155
KeyCare Plus (R6,251 to R8,300) R747 R747 R208
KeyCare Plus (R8,301+) R1,112 R1,112 R297
Coastal Core R819 R614 R327
Essential Delta Core R775 R581 R311
Essential Core R969 R726 R388
Classic Delta Core R903 R710 R361
Classic Core R1,128 R888 R451
Coastal Saver R1,172 R877 R472
Essential Delta Saver R963 R722 R384
Essential Saver R1,204 R902 R481
Classic Delta Saver R1,212 R953 R485
Classic Saver R1,516 R1,193 R606
Essential Priority R1,460 R1,147 R582
Classic Priority R1,698 R1,337 R680
Essential Delta Comprehensive R1,916 R1,811 R383
Essential Comprehensive R2,129 R2,012 R425
Classic Delta Comprehensive R2,281 R2,157 R454
Classic Comprehensive R2,533 R2,396 R506
Executive R3,089 R3,089 R586
Single member Member + 1 Member + 2 +
Vitality R125 R145 R153
KeyFit R27 R33 R42
Vitality and KeyFit R133 R158 R177