External Medical Items

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What are External Medical Items?

External medical items are used to assist or substitute parts of the body that are non-functional or missing. These items can withstand repeated use and can be inserted and taken out without surgical intervention.

How we pay for external medical items

We pay for external medical items from you day-to-day benefits subject to an overall annual limit, which depends on your plan.

Additionally, members on Executive and Comprehensive plans can also apply for additional cover through the External Medical Items Extender Benefit when they have reached their overall annual EMI benefit limit.

External medical items are funded at 100% of the Discovery Health Rate up to an overall annual limit, which varies according to plan type.

Cover:

External Medical Items are covered from available funds in your Medical Savings Account and Above Threshold Benefit.

This benefit is subject to the annual limit.

Important infomation to know:

When your Medical Savings Account is used up and you are in the Self-Payment Gap, you are responsible to fund External Medical Items yourself.

This is not a separate benefit and limits apply to claims paid from your Medical Savings Account, paid by you (if you are in a self-payment gap) and Above Threshold Benefit. This limit will be adjusted if you join the Scheme after January.

Frequency Limits for External Medical Items

Certain categories of external medical items have a frequency limit.

  • Wheelchairs, scooters and other specialised appliances for members with physical disability

    One every (3) years

  • Crutches

    Two individual crutches or one pair per year

  • Hoist

    One every 2 years

  • Commode

    One per year

  • Walkers

    One every three (3) years

  • CPAP's (Contiunous Positive Airway Pressure) APAP's (Automatic Positive Airway Pressure) VPAP's (Variable Positive Airway Pressure)

    One every three (3) years

  • Nebulisers

    One per year

  • Portable Oxygen Concentrator

    One every three (3) years

  • Insulin Pump (Entry level and Sensor Augmented pumps)

    One every four (4) years

  • Breast Pump

    One per year

  • Blood Pressure Monitors

    One per year

  • Glucometers

    One per year

  • Apnoea and Movement monitors

    One per year

Preferred Suppliers for External Medical Items

Please refer to the External Medical Items benefit guide for a full list of preferred suppliers for selected external medical items. Note that not all products supplied by these suppliers are preferred. Please contact us for the specific list of preferred products.

Claims for non-preferred products, purchased from a preferred or non-preferred provider will be paid up to the applicable reference price.

External Medical Items Extender Benefit

The EMI Extender benefit gives members with specific severe, complex medical conditions extended cover for clinically appropriate and cost effective external medical items as determined by Discovery Health Medical Scheme, subject to the Scheme’s guidelines and managed care criteria.

The External Medical Items (EMI) Extender Benefit is only available after you reach your overall annual External Medical items (EMI) benefit limit and you apply for cover.

When your application is approved for the External Medical Items Extender Benefit we will fund your claims up to the Discovery Health Rate for approved items. If your healthcare provider charges more than the Discovery Health Rate, you will need to pay the difference.

For a list of conditions and product categories for which we will consider applications for extended cover, please refer to the External Medical Items benefit guide.

All cases will be reviewed on individual merit and on a case-by-case basis, with the severity of the condition and disability taken into account.

How to apply for the External Medical Items Extender Benefit

You need to complete the External Medical Items Extender Benefit application form and email this through to us on Clinicalhelp@discovery.co.za

EMI Extender benefit application form (PDF)

Classic plans:

External Medical Items are covered from available funds in your Medical Savings Account and Above Threshold Benefit, subject to the annual limit.

Classic Smart

Comprehensive Plan

Does not cover External Medical Items and you will need to pay these expenses yourself if this is your chosen plan.

Essential Plans:

External Medical Items are covered from available funds in your Medical Savings Account and Above Threshold Benefit, subject to the annual limit.

Important infomation to know:

When your Medical Savings Account is used up and you are in the Self-Payment Gap, you are responsible to fund External Medical Items yourself.

This is not a separate benefit and limits apply to claims paid from your Medical Savings Account, paid by you (if you are in a self-payment gap) and Above Threshold Benefit. This limit will be adjusted if you join the Scheme after January.

Frequency Limits for External Medical Items

Certain categories of external medical items have a frequency limit.

  • Wheelchairs, scooters and other specialised appliances for members with physical disability

    One every (3) years

  • Crutches

    Two individual crutches or one pair per year

  • Hoist

    One every 2 years

  • Commode

    One per year

  • Walkers

    One every three (3) years

  • CPAP's (Contiunous Positive Airway Pressure) APAP's (Automatic Positive Airway Pressure) VPAP's (Variable Positive Airway Pressure)

    One every three (3) years

  • Nebulisers

    One per year

  • Portable Oxygen Concentrator

    One every three (3) years

  • Insulin Pump (Entry level and Sensor Augmented pumps)

    One every four (4) years

  • Breast Pump

    One per year

  • Blood Pressure Monitors

    One per year

  • Glucometers

    One per year

  • Apnoea and Movement monitors

    One per year

Preferred Suppliers for External Medical Items

Please refer to the External Medical Items benefit guide for a full list of preferred suppliers for selected external medical items. Note that not all products supplied by these suppliers are preferred. Please contact us for the specific list of preferred products.

Claims for non-preferred products, purchased from a preferred or non-preferred provider will be paid up to the applicable reference price.

External Medical Items Extender Benefit

The EMI Extender benefit gives members with specific severe, complex medical conditions extended cover for clinically appropriate and cost effective external medical items as determined by Discovery Health Medical Scheme, subject to the Scheme’s guidelines and managed care criteria.

The External Medical Items (EMI) Extender Benefit is only available after your reach your overall annual External Medical items (EMI) benefit limit and you apply for cover.

When your application is approved for the External Medical Items Extender Benefit we will fund your claims up to the Discovery Health Rate for approved items. If your healthcare provider charges more than the Discovery Health Rate, you will need to pay the difference.

For a list of conditions and product categories for which we will consider applications for extended cover, please refer to the External Medical Items benefit guide.

All cases will be reviewed on individual merit and on a case-by-case basis, with the severity of the condition and disability taken into account.

How to apply for the External Medical Items Extender Benefit

You need to complete the External Medical Items Extender Benefit application form and email this through to us on Clinicalhelp@discovery.co.za

EMI Extender benefit application form (PDF)

Classic plans:

External Medical Items are covered from available funds in your Medical Savings Account and Above Threshold Benefit, subject to an annual limit and subject to the limited Above Threshold Benefit.

Essential plans:

External Medical Items are covered from available funds in your Medical Savings Account and Above Threshold Benefit, subject to an annual limit and subject to the limited Above Threshold Benefit.

Important information to know:

This is not a separate benefit and limits apply to claims paid from your Medical Savings Account, paid by you (if you are in a self-payment gap) and Above Threshold Benefit. This annual limit will be adjusted if you join the Scheme after January.

Frequency Limits for External Medical Items

Certain categories of external medical items have a frequency limit.

  • Wheelchairs, scooters and other specialised appliances for members with physical disability

    One every (3) years

  • Crutches

    Two individual crutches or one pair per year

  • Hoist

    One every 2 years

  • Commode

    One per year

  • Walkers

    One every three (3) years

  • CPAP's (Contiunous Positive Airway Pressure) APAP's (Automatic Positive Airway Pressure) VPAP's (Variable Positive Airway Pressure)

    One every three (3) years

  • Nebulisers

    One per year

  • Portable Oxygen Concentrator

    One every three (3) years

  • Insulin Pump (Entry level and Sensor Augmented pumps)

    One every four (4) years

  • Breast Pump

    One per year

  • Blood Pressure Monitors

    One per year

  • Glucometers

    One per year

  • Apnoea and Movement monitors

    One per year

Preferred Suppliers for External Medical Items

Please refer to the External Medical Items benefit guide for a full list of preferred suppliers for selected external medical items. Note that not all products supplied by these suppliers are preferred. Please contact us for the specific list of preferred products.

Claims for non-preferred products, purchased from a preferred or non-preferred provider will be paid up to the applicable reference price.

External Medical Items are covered from the available funds in your Medical Savings Account.

Preferred Suppliers for External Medical Items

Please refer to the External Medical Items benefit guide for a full list of preferred suppliers for selected external medical items. Note that not all products supplied by these suppliers are preferred. Please contact us for the specific list of preferred products.

Claims for non-preferred products, purchased from a preferred or non-preferred provider will be paid up to the applicable reference price.

External medical items are not covered on Core plans. You will need to pay for these expenses yourself.

External medical items are not covered on Smart plans. You will need to pay for these expenses yourself.

On KeyCare Plus, we cover wheelchairs, wheelchair batteries and cushions, transfer boards and mobile ramps, commodes, long-leg calipers, crutches and walkers on the medical equipment list, if you get them from a network provider. This benefit is subject to an annual limit.

External medical items are not covered on KeyCare Start and KeyCare Core plans. You will need to pay for these expenses yourself.

 
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