Medical Cover

As a member of Discovery Health Medical Scheme you have access to the broadest and best level of healthcare cover in the market based on your medical needs.

Day-to-day cover
We pay for your day-to-day medical expenses like GP and specialist face-to-face and video call consultations, everyday medicine, radiology and pathology from the Medical Savings Account (MSA), Day-to-day Extender Benefit (DEB) and Above Threshold Benefit (ATB). The level of day-to-day cover depends on the plan you choose.

Medical Savings Account (MSA) on the Executive, Comprehensive, Priority and Saver plans
The Medical Savings Account (MSA) is only applicable to the Executive, Comprehensive (excluding Classic Zero MSA), Priority and Saver Plans. It is a fixed amount that the Scheme gives you at the beginning of the year. Your total MSA amount and contribution is calculated as a fixed portion (15%, 20% or 25%, depending on your plan type) of your total and monthly contribution.

Any unused funds in your MSA will carry over to the next year. On the Executive, Comprehensive and Priority plans, when you run out of MSA, you will have to pay for some healthcare expenses from your pocket before you reach your Annual Threshold for the Above Threshold Benefit (ATB) to kick in. This temporary gap in cover is called a Self-payment Gap (SPG). You must still send claims to us so that we know when to start paying from your ATB.

Day-to-day Extender Benefit (DEB)
On selected plans, when you have spent your annual Medical Saving Account (MSA) allocated, the Day-to-day Extender Benefit (DEB) extends your day-to-day cover for essential healthcare services in our network.

Select day-to-day benefits on the Smart, KeyCare Plus and KeyCare Start plans
Smart plans offer unlimited cover for GP consultations and other day-to-day benefits with fixed payments in the Smart Network. The KeyCare Plus and Start plans offer primary care cover through your chosen GP and day-to-day medicine from our medicine list.

In hospital

You get unlimited hospital cover. For any planned or non-emergency admission you need to call us to confirm your admission. Some of our plans offer cover for planned admissions in a defined network. These plans include Delta options, Smart, Coastal and KeyCare plans. For planned admissions at hospitals outside these networks, and you will have to pay a portion of the hospital account.

In an Emergency

If you have an emergency, you can go straight to hospital. If you need medically-equipped transport, call Discovery 911 on 0860 999 911.

You can get full cover when using our networks

Hospitals
If you have chosen a plan with a hospital network, make sure you use a hospital in that network to get full cover.

Medicine
Use MedXpress, a convenient cost-effective medicine ordering service or a MedXpress network pharmacy to enjoy full cover and avoid co-payments when claiming for medicine on the medicine list. Alternatively, you can use one of over 2 500 pharmacies in our network. Cover depends on your chosen plan.

GPs and specialists
You have full cover for GPs and specialists who we have payment arrangements with.

Day-to-day Extender Benefit
Use a network GP on HealthID who meets the digital criteria to access your Day-to-Day Extender Benefits and get full cover for GP consultation fees and kids casualty visits. Cover depends on the plan you choose.

You get extensive cover for maternity, chronic conditions and cancer

Members who are pregnant, and members who have a chronic illness or cancer get the best care and support at all times through our suite of benefits and programmes.

Oliver Healthcare is a Discovery Affiliated Independent Financial Advisor
Information source: Discovery

No matter the option you choose, you have access to great benefits

Every Momentum Medical Scheme member can enjoy a variety of benefits that include, preventative care, hospitalisation, Day-to-day Benefits, access to chronic medication, and 24/7 medical advice at no extra cost.

Information source: Momentum

Flexible cover for every stage of your life

We offer an option for every life stage and healthcare need. For members who are looking for choice, flexibility and control, and who also want to know that their healthcare requirements as single people, young couples or growing families are met, our flexiFED range is ideal. And, thanks to our innovative MediVault and Wallet facility, members on flexiFED can save on their monthly contribution whilst still having access to funds for day-to-day medical expenses.

We also offer comprehensive options that provide generous amounts of day-to-day cover like maxima PLUS for members who don’t want to leave anything to chance, or who might have more serious healthcare needs.

We even cater for the needs of previously uncovered employees with our low cost, entry-level medical aid product called myFED.

Unique to fedhealth

• Unlimited Network doctor’s visits – Members can see their GP as often as they need on most options, by either visiting any network GP or a nominated network GP (depending on the option)
• Child rates for financially dependent children up to 27 years of age
• Upgrades to higher options any time of the year on diagnosis of a dread disease or life-changing event, like a pregnancy

We pay more from Risk than other schemes

• Post-hospitalisation treatment for up to 30 days after discharge from hospital (e.g. physiotherapy, x-rays, pathology)
• 7 days of take-home medication
• Specialised radiology like MRI and CT scans – whether admitted to hospital or not. Co-payment may apply depending on the option
• Trauma treatment at a casualty ward – whether admitted to hospital or not. Co-payment may apply depending on the option
• Monthly prescriptions for female contraception, including oral, patches, certain injectables, contraceptive rings as well as IUDs that include Mirena®, on most options.
• In-hospital dentistry for children under 7 – The hospital and anaesthetist costs are covered from the core benefit bundle, while the dentist is paid for by the member. Not applicable to flexiFED 1

More support when you need it

• The Fedhealth Family Room, our online member portal
• The Fedhealth Baby Programme
• Paed-IQ
• 24-Hour Fedhealth Nurse Line
• Emergency transport/response through Europ Assistance
• Comprehensive managed care programmes:
• Aid for AIDS (AfA) for those living with HIV/AIDS
• Oncology Disease Management supports cancer sufferers with comprehensive care including cover for chemotherapy, radiotherapy, approved medication, related consultations, pathology and general radiology.
• Mental Health Programme provides qualifying members who have mental health or substance abuse issues with access to the best quality primary mental healthcare.
• Emotional Wellbeing Programme gives members free telephonic support and advice through those stressful curveballs life throws at us, and can put them in touch with a psychologist at a reduced rate if required.
• Conservative Back and Neck Rehabilitation Programme helps qualifying members address their back and neck issues to avoid spinal surgery. Over six weeks, members benefit from a multidisciplinary approach including a GP, physio and biokineticist to assess and treat their condition.
• Smoking Cessation Programme – All members on all options can sign up for the GoSmokeFree service at 200 pharmacies countrywide to help them kick the habit for good. This programme will be paid from Risk.
• Weight Management Programme is a 12-week programme designed for qualifying Fedhealth members with a high BMI and waist circumference. Led by a biokineticist, members have access to a dietician and behavioural psychologist with the goal to lose the excess weight and lead healthier, more rewarding lives.
• MediTaxi – A free transport service to take members with hospital authorisations to follow-up medical appointments.
• SOS Call Me – Our user-friendly call-back service for members and dependants.

Caring for corporates

For corporate organisations joining the Scheme we offer various initiatives to meet company-specific demands:

• Group implementation and training ensures a smooth transition from previous schemes to Fedhealth
• A dedicated Account Executive (AE) for each organisation with 25 or more staff members – regular visits take place and the AE is always available to solve queries online
• A dedicated credit controller per organisation
• Tailor-made solutions with option mapping to cater directly to the organisation’s staff
• Update – an electronic newsletter aimed directly at HR/Finance departments delivers scheme-related news to employers.

Our provider network

When it comes to giving our members quality healthcare they can trust, we partner with healthcare professionals with the same passion for healthcare. After all, only the best will do for our members!

We’ve negotiated dispensing fees with Clicks, MediRite, Dis-Chem and Pharmacy Direct, as well as plenty of smallerpharmacies. This provides price certainty for our members, regardless of where they live in South Africa.

We have over 5 873 General Practitioners currently contracted to the Fedhealth GP Network. As such 97% of our principal members have access to a Network Doctor within a 10km radius of where they live. And more than 81% of claiming beneficiaries on all comprehensive and saver options are already using Network Doctors. On most options, members have access to unlimited GP visits.

We have over 4 736 specialists from all disciplines contracted to the Fedhealth Specialist Network. Using a Fedhealth Network Specialist means no co-payments and truly unlimited benefits at cost for members in-hospital and price certainty out-of-hospital.

We’ve also established partnerships with excellent hospitals across the country. This partnership provides immense financial peace of mind for members, and allows the Scheme to provide sound benefits at affordable rates.

Information source: Fedhealth

Our provider network

We live in a world of acronyms and industry-specific jargon, which does little to offset the anxiety and confusion of consumers. Understanding your medical aid terms will help you to get the most out of your benefits. Gerhard Van Emmenis, Principal Officer of Bonitas Medical Fund gives the lowdown on terms you need to know.

Principal member

This is the main member on the medical aid scheme. Either one person or someone who has registered one or more dependants. The principal member pays a larger contribution than the dependants do. Medical schemes refer to principal members and dependants as beneficiaries.

Waiting periods

According to the Medical Schemes Act 131 of 1998, medical aid schemes are entitled to impose waiting periods on new members. This protects other members of the Fund by ensuring that individuals aren’t able to make large claims shortly after joining and then cancelling their membership. Unlike other financial products, medical schemes are not-for-profit entities, they are highly regulated to ensure they fulfil a social solidarity role, ie everyone benefits from the dependence individuals have on each other. There are two types of waiting periods, general waiting periods (up to three months and condition-specific waiting periods (up to 12 months).

During a general waiting period a beneficiary is not entitled to any benefits (in some instances not even Prescribed Minimum Benefits (PMBs). Condition-specific waiting periods are related to a specific medical condition. During this time a beneficiary is not entitled to any benefits for a particular condition for which medical advice, diagnosis, care or treatment was recommended or received.

Late-joiner penalties

In South Africa, medical aid schemes can impose late-joiner penalties on individuals who join a medical aid scheme after the age of 35; those who have never been medical aid members; or those who have not belonged to a medical aid scheme for a specified period of time since April 2001.

If you are over 35 and haven’t been on a medical aid then – depending on your age – you will be penalised and charged a surcharge between a 25% and up to 75% loading of your premium. This is outlined by the Council for Medical Schemes but at the discretion of the scheme.

Designated Service Provider (DSP)

This refers to a healthcare practitioner (doctor, pharmacist, hospital etc) that has been contracted by your medical aid as the first choice when you need diagnosis or treatment. The scheme generally agrees to pay these providers a specific rate for these services.

‘Negotiating with healthcare providers is critical to make sure that members get maximum value for money. It also allows us to monitor service to ensure that members receive care and services of the highest quality’, Van Emmenis explains. If you choose not to use the DSP, you may have to make a co-payment, which is an addition cost from your own pocket. You do not need to go to a DSP in an emergency or if there is no DSP within reasonable distance.

Acute versus chronic conditions

Acute is severe and sudden in onset and could describe anything from a broken bone to an allergic reaction. A chronic condition, by contrast is a long-developing syndrome usually lasting more than three months for which you’ll need ongoing treatment, such as diabetes or hypothyroidism. It usually requires life-long treatment and daily medicine to improve quality of life.

Prescribed Minimum Benefits (PMBs)

These are a set of defined benefits to ensure that all medical scheme members have access to certain minimum health services, regardless of the benefit option they have selected. The aim is to provide people with continuous care to improve their health and wellbeing and to make healthcare more affordable. The Medical Schemes Act requires all medical schemes to pay ‘in full’ for the medical care, pathology, radiology and medication costs related to: The diagnosis, treatment and care of:

• Emergency medical conditions
• A list of 270 medical conditions (known as Diagnosis Treatment Pairs), which includes
• 27 common chronic conditions (defined in the Chronic Disease List)

This means that, by law, your medical scheme has to pay your claims for the diagnosis of and consultations or treatment of a PMB. Remember, however, that you may be required to inform your medical scheme of your condition to ensure that your treatment is paid for correctly. In addition, schemes may require that you use a specific provider.

Hospital plan

A hospital plan provides you with basic but important medical cover. It covers a range of treatment and procedures when you are admitted into hospital. All hospital plans, however, have to pay for chronic medication prescribed for the 27 PMB chronic conditions. ‘Always look at the benefits provided by hospital plans carefully when selecting one, as some offer additional benefits that offer more value for money,’ says Van Emmenis.

Pre-authorisation

Hospital admissions for non-essential or non-life threatening procedures need to be authorised by your medical aid prior to being admitted. Unless there is a medical emergency, you will have to get pre-authorisation. If you do not have pre-authorisation, the scheme can refuse to pay. Pre-authorisations are obtained by contacting your scheme administrator at least three days before admission.

Exclusions

Some medical conditions and procedures may be excluded from medical schemes e.g. cosmetic surgery and self-inflicted injuries.

So, get to know your DSPs from your PMBs to ensure you understand what you are covered for and how to get the most out of your medical aid or hospital plan.

Information source: Bonitas

Foundation

IDEAL OPTION FOR: ENTRY-LEVEL EMPLOYEES
Specifically designed for the corporate market, the Foundation option caters for the unique healthcare needs of entry-level staff, at exceptionally affordable rates.

1. Unlimited private hospitalisation for all Prescribed Minimum Benefits (PMB’s)
2. Balanced day-to-day benefits**
3. Great preventative care benefits**
4. Excellent specialist care**
5. Cover for 29 chronic conditions
6. Maternity benefits including 2 Scans and visits to your GP or Midwife

* Scheme protocols apply ** Network providers

Rise

IDEAL OPTION FOR: SINGLE, YOUNG ADULTS
Serving as the ideal option for the young and healthy who are starting out in life, Rise provides quality hospital cover at the industry’s most affordable rates.

1. Belonging to the industry’s most affordable hospital option
2. An unlimited hospitalisation benefit at our extensive range of network hospitals
3. Excellent chronic cover for 29 conditions
4. Great maternity benefits that include 2x GP or Specialist visits and 2D scans
5. Oncology cover for a wide variety of Prescribed Minimum Benefit (PMB) conditions

Aspire

IDEAL OPTION FOR: YOUNG, HEALTHY COUPLES IN NEED OF AFFORDABLE HOSPITAL COVER
The Aspire option was specifically designed around the needs of young and healthy couples who are looking for extensive in-hospital benefits, as well as a few added extras.

1. Excellent value for money
2. Unlimited hospitalisation at any hospital
3. 2 GP consultations per year
4. Excellent maternity cover including two 2D scans
5. Generous post-operative care including a 10 day hospice, rehab or step-down facility benefit
6. Cover for 29 chronic conditions
7. Psychology & psychiatry benefits*

* Prescribed Minimum Benefits (PMB) conditions and at network providers

Flex & Flex Plus

IDEAL OPTION FOR: HEALTHY YOUNG FAMILIES
A clear leader in its category, the Flex and Flex Plus options were specifically developed around the needs of young and healthy families who need affordable cover without compromising benefits. With cost being a key consideration at this life stage, the range offers two options: Flex where hospital and chronic benefits are accessed via our extensive range of network providers and Flex Plus where any provider can be used.

1. Belonging to one of the industry’s most affordable and benefit rich options in this category
2. Unlimited private hospitalisation at our wide range of network hospitals
3. Excellent maternity benefits including 3 specialist visits and 3 scans (2x2D and 1x3D)
4. A handy casualty benefit
5. Extensive day-to-day benefits of more than R30 000, including generous cover for GP and Specialist visits
6. A unique Flexi Benefit to further boost your already impressive day-to-day cover
7. Great advanced dentistry benefit that includes cover for crowns and bridges
8. Excellent cover for 29 chronic conditions

Advance

IDEAL FOR: YOUNG AND HEALTHY FAMILIES IN NEED OF COMPREHENSIVE COVER WITH A SAVINGS COMPONENT
The Advance option is perfectly suited to young couples wanting to start a family or those who have already added a youngster to the crew. Offering exceptional cover at truly affordable rates, the Advance option will ensure that this family’s unique healthcare needs are more than covered.

1. Belonging to one of the industry’s best options in this category
2. Unlimited hospitalisation at any private hospital
3. A unique combination of day-to-day benefits that provide both flexibility in the form of a generous savings account, as well as security in the form of traditional (stated) benefits
4. A wide range of preventative care benefits to keep your family as healthy as possible, for as long as possible
5. Fantastic maternity benefits including scans and antenatal classes
6. A generous R20 000 benefit for MRI and CT scans*

* In- and out-of-hospital

Optimum

IDEAL OPTION FOR: LARGER FAMILIES WITH ONE OR TWO YOUNG CHILDREN
The Optimum option offers quality traditional healthcare cover with the added feature of a medical savings account. Ideally suited to larger or more mature families who are looking for more generous cover and the freedom of choice when it comes to their day-to-day healthcare needs, the Optimum option offers some of the industry’s most comprehensive benefits at highly competitive premiums.

1. Unlimited hospitalisation at any private hospital
2. A generous Medical Savings Account for your family’s day-to-day needs
3. A unique Benefit Booster™ that takes your day-to-day benefits from impressive to the best in its category
4. Extensive chronic disease cover including 35 conditions and biological entities
5. Comprehensive preventative care benefits to help you and your loved ones take proactive care of your health
6. Excellent maternity benefits including 10 prenatal midwife visits, 3 scans and antenatal classes
7. Extended cover for investigative and surgical procedures done in consulting rooms (covered at 200% of Scheme rate)

Millennium

IDEAL OPTION FOR: LARGER FAMILIES IN NEED OF COMPREHENSIVE, FLEXIBLE COVER
One of the industry’s best of breed new generation options, the Millennium range offers the ideal level of cover for larger or more mature families with its more than generous savings accounts and excellent in-hospital benefits. With affordability being a key consideration, the range offers options:

1. Millennium where benefit access extends to any provider at a slightly higher monthly premium.
2. Only paying for your first 2 children with the 3rd and subsequent children covered for free
3. Unlimited private hospitalisation at any hospital
4. No co-payments on tonsillectomy and adenoids
5. An excellent advanced dentistry benefit
6. Extensive preventative care benefits for the whole family
7. Comprehensive cover for 59 chronic conditions including ADHD and Allergic Rhinitis

Cobalt

IDEAL OPTION FOR: MATURE MEMBERS AND FAMILIES IN NEED OF COMPREHENSIVE, FLEXIBLE COVER
The Cobalt option leaves no healthcare stone unturned with a quality savings account + a generous Benefit Booster™ for day-to-day care. Combined with extensive in-hospital care, this option is the natural choice for families in need of extensive cover, and freedom of choice when it comes to their day-to-day benefits.

1. Unlimited hospitalisation at any private hospital
2. More than generous medical savings account
3. The unique Benefit Booster™ for extra day-to-day benefits
4. Superior oncology cover, including biological therapies
5. Added care in the form of a convenient benefit for clinic nurse visits
6. Excellent cover for 42 chronic conditions, including a R63 000 benefit for biological entities
7. Quality preventative care benefits to help your family take proactive care of their health

Information source: Health Squared

Information source: Medshield