Important Health Plan Definitions

Use these handy definitions to help you understand important concepts related to you Health Plan:

Discovery Health Glossary & Definitions

Familiarise yourself with the various Important Health Plan Definitions on Discovery Health and be Informed…

  • Discovery Health Rate – This rate is the rate set by Discovery Health at which claims and services for healthcare providers (hospitals, pharmacies and healthcare professional) will be paid.
  • Payment Arrangements – The Scheme has entered into payment arrangements with various healthcare professional that have agreed to reimburse at the Discovery Health Rate. This ensures no co-payments for you. You benefit from access to the broadest range of GP’s and specialists, which represent almost 90% of members’ interactions with these healthcare professionals.
  • Networks – Some plans, benefits and healthcare services require you to use the Scheme’s network providers. If you use these providers Discovery is able to keep your contributions as affordable as possible while ensuring full cover.
  • Medicine List – This is a list of approved chronic medicines that the Scheme covers in full. The list includes an extensive range of high-quality medicines for all covered chronic conditions to ensure you always have an option of full cover.
  • Limits – Most in-and out-of-hospital healthcare benefits are unlimited but there are some healthcare services such as dentistry and optometry that are subject to annual limits. It is important that you familiarise yourself with these limits and to track your usage by logging onto www.discovery.co.za or checking your statements.
  • Hospital Cover – Discovery covers you in hospital for emergency and planned hospital admissions. You have to get authorisation from Discovery for your hospital stay. Your hospital cover is made up of your hospital account and related accounts. A related account is an account from your treating doctor, anaesthetist and any other approved healthcare services like pathology or radiology scans.
  • Prescribed Minimum Benefits (PMB) conditions – These are conditions which all Medical Schemes are required to cover as set by the Council for Medical Schemes according to clinical guidelines. You may be required to use a Designated Service Provider (DSP). A DSP is a hospital or healthcare provider who has an arrangement wit the Discovery Health Medical Scheme to provide treatment or services at a contracted rate and without any co-payments.
  • Chronic Illness Benefit (CIB) – The Chronic Illness Benefit covered a comprehensive list of chronic conditions that include asthma, diabetes, high cholesterol and high blood pressure. The Chronic Disease List (CDL) is a defined list of chronic conditions that Discovery covers according to Prescribed Minimum Benefits. Executive and Comprehensive plans offer cover for additional chronic conditions. You have full cover for approved medicine on the Scheme’s medicine list or up to a set monthly Chronic Drug Amount for medicines not on the medicine list. The Chronic Drug Amount

OUT-OF-HOSPITAL

  • Day -to-Day Cover – Day-to-Day cover includes your visits to healthcare professional out of hospital, radiology, pathology, and medicines purchased for everyday use. Discovery covers your Day-to-Day healthcare services from the Medical Savings Account, Insured Network Benefit and the Above Threshold Benefit. The level of Day-to-Day cover depends on your plan choice.
  • Medical Savings Account (MSA) – This is an amount that gets set aside for at the beginning of the year or when you join the Scheme. You can use it for Day-to-Day healthcare expenses like doctor’s visits, optometry, medicine, pathology and radiology as longs a you have money available. Money not used at the end of the year will be carried over to the next year.
  • Self-payment Gap (SPG) – This is a temporary gap in cover when you run out of funds in you MSA but have not yet reached your Annual Threshold. You will have to pay Day-to-Day claims from your own pocket during this period. You must still submit claims to Discovery so that they know when to start paying from the Above Threshold Benefit.
  • Insured Network Benefit (INB) – This unique benefit gives you unlimited Day-to-Day cover for a set of healthcare services at a network provider when you have spent the annual funds in your Medical Savings Account. These healthcare services include GP consultations fees, Day to-Day cost-effective medicines, blood tests, maternity costs and durable external medical items. The level of cover depends on the plan you choose.
  • Above Threshold Benefit (ATB) – The Above Threshold Benefit gives you extra cover at the Discovery Health Rate or a percentage of it when yours claims add up to a set amount call the Annual Threshold. The ATB applies to the Executive Plan, Comprehensive Plans and Priority Plans. The ATB has a limit on the Priority Plans.