Consultations with Healthcare Professionals

We recognise that health professionals play a critical role in helping you improve your health and wellbeing by sharing their expert knowledge. We believe that we have a responsibility to you, our member and our industry to use our experience, our expertise and our scale to help keep private healthcare cover affordable. That is why we have entered into arrangements with specialists and GPs which offer them a higher rate of reimbursement while ensuring you have limited co-payments.

How our payment arrangements benefit you?

You can benefit by using healthcare professionals who we have an arrangement with because we will cover their approved consultations and procedures in full. We pay claims directly to the healthcare professional when we have an arrangement with them.

Where we don't have arrangements with a healthcare professional, we pay you directly if the claim is higher than the Discovery Health Rate. You are responsible for settling the claim directly with the doctor.

Note that you can have full or partial cover, depending on the provider. Full cover means that your claim will be paid in full by Discovery Health Medical Scheme. On the other hand, partial cover means that Discovery Health Medical Scheme will only pay for a portion of your claim and so you will need to pay for any shortfalls yourself.

Cover for General Practitioners (GPs)

Out-of-hospital

We pay GP claims up to 100% of the Discovery Health Rate (DHR) from the available funds in your Medical Savings Account (MSA).

Additionally, we pay GP claims up to 100% of the Discovery Health Rate from your Above Threshold Benefit when you have reached your Annual Threshold.

You also have extended cover through the Day-to-day Extender Benefit (DEB) when you have spent your annual MSA allocation.You can read more on this benefit here.

In-hospital

We will pay for these claims in full from your Hospital Benefit if you use a GP that we have a payment arrangement with, as long as their accounts are part of an approved hospital admission.

We pay up to 200% of the Discovery Health Rate (DHR) for GPs that we do not have a payment arrangement with, as long as their accounts are part of an approved hospital admission.

Cover for Specialists

Out-of-hospital

We pay specialist claims up to an agreed rate for specialists we have a payment arrangement with and up to three times (300%) the Discovery Health Rate (DHR) for specialists we don't have a payment arrangement with.

We pay these claims from the available funds in your Medical Savings Account (MSA) or from your Above Threshold Benefit, when you have reached your Annual Threshold.

If you have run out of funds in your Medical Savings Account and have not yet reached your Annual Threshold (you are in the Self-payment Gap), you will need to pay these accounts.

In-hospital

We will pay for these claims in full from your Hospital Benefit if you use a specialist that we have a payment arrangement with, as long as their accounts are part of an approved hospital admission.

We pay up to 300% of the Discovery Health Rate (DHR) for specialists that we do not have a payment arrangement with, as long as their accounts are part of an approved hospital admission.

Cover for Allied, Therapeutic and Psychology

This includes acousticians, biokineticists, chiropractors, counsellors, dieticians, homeopaths, nurses, occupational therapists, physiotherapists, podiatrists, psychologists, psychometrists, social workers, speech and language therapists, and audiologists.

Please refer to the Allied, Therapeutic and Psychology benefit guide for more information.

Out-of-hospital

We pay for out-of-hospital allied, therapeutic and psychology healthcare services from the available funds allocated to your Medical Savings Account and from the Above Threshold Benefit once your claims add up to the Annual Threshold. We pay these claims up to a maximum of 100% of the Discovery Health Rate. If your healthcare provider charges above this rate, you will need to pay the balance.

Claims will add up to, and pay out from, your Above Threshold Benefit at 100% of the Discovery Health Rate once you reach your Annual Threshold.

If you have run out of funds in your Medical Savings Account and have not yet reached your Annual Threshold (you are in the Self-payment Gap), you will need to pay these accounts.

This benefit has a limit and is not a separate benefit. Limits apply to claims paid from your Medical Savings Account, claims paid by you (if you are in a self-payment gap) and claims paid from your Above Threshold Benefit.

In-hospital

We cover these from the Hospital Benefit at 200% of the Discovery Health Rate.

Cover for General Practitioners (GPs)

Out-of-hospital

We pay GP claims up to 100% of the Discovery Health Rate (DHR) from the available funds in your Medical Savings Account (MSA).

On Classic Smart Comprehensive, you pay R55 of the consultation fee with the balance of this fee covered up to the DHR. Video consultations are covered in full up to the DHR. You must go a GP in the Smart GP Network.

Additionally, we pay GP claims up to 100% of the Discovery Health Rate from your Above Threshold Benefit when you have reached your Annual Threshold.

You also have extended cover through the Day-to-day Extender Benefit (DEB) when you have spent your annual MSA allocation.You can read more on this benefit here.

In-hospital

We will pay for these claims in full from your Hospital Benefit if you use a GP that we have a payment arrangement with, as long as their accounts are part of an approved hospital admission.

We pay up to 200% of the Discovery Health Rate (DHR) on Classic plans, and up to 100% of the DHR for Essential plans for GPs that we do not have a payment arrangement with, as long as their accounts are part of an approved hospital admission.

Cover for Specialists

Out-of-hospital

We pay specialist claims up to an agreed rate for specialists we have a payment arrangement with and up to the Discovery Health Rate (DHR) for specialists we don't have a payment arrangement with.

We pay these claims from the available funds in your Medical Savings Account (MSA) or from your Above Threshold Benefit, when you have reached your Annual Threshold.

If you have run out of funds in your Medical Savings Account and have not yet reached your Annual Threshold (you are in the Self-payment Gap), you will need to pay these accounts.

On Classic Smart Comprehensive, you have cover for physician, gynaecologist, paediatrician and ENT consultations up to the annual benefit limit of R5 000 per person per year or R10 000 a family a year if referred by your Smart Network GP.

In-hospital

We will pay for these claims in full from your Hospital Benefit if you use a specialist that we have a payment arrangement with, as long as their accounts are part of an approved hospital admission.

We pay up to 200% of the Discovery Health Rate (DHR) on Classic plans, and up to 100% of the DHR for Essential plans for specialists that we do not have a payment arrangement with, as long as their accounts are part of an approved hospital admission.

Cover for Allied, Therapeutic and Psychology

This includes acousticians, biokineticists, chiropractors, counsellors, dieticians, homeopaths, nurses, occupational therapists, physiotherapists, podiatrists, psychologists, psychometrists, social workers, speech and language therapists, and audiologists.

Please refer to the Allied, Therapeutic and Psychology benefit guide for more information.

Out-of-hospital

We pay for out-of-hospital allied, therapeutic and psychology healthcare services from the available funds allocated to your Medical Savings Account and from the Above Threshold Benefit once your claims add up to the Annual Threshold. We pay these claims up to a maximum of 100% of the Discovery Health Rate. If your healthcare provider charges above this rate, you will need to pay the balance.

Claims will add up to, and pay out from, your Above Threshold Benefit at 100% of the Discovery Health Rate once you reach your Annual Threshold.

If you have run out of funds in your Medical Savings Account and have not yet reached your Annual Threshold (you are in the Self-payment Gap), you will need to pay these accounts.

This benefit has a limit and is not a separate benefit. Limits apply to claims paid from your Medical Savings Account, claims paid by you (if you are in a self-payment gap) and claims paid from your Above Threshold Benefit.

In-hospital

We cover these from the Hospital benefit at 100% of the Discovery Health Rate.

Cover for General Practitioners (GPs)

Out-of-hospital

We pay GP claims up to 100% of the Discovery Health Rate (DHR) from the available funds in your Medical Savings Account (MSA).

Additionally, we pay GP claims up to 100% of the Discovery Health Rate from your Above Threshold Benefit when you have reached your Annual Threshold.

You also have extended cover through the Day-to-day Extender Benefit (DEB) when you have spent your annual MSA allocation.You can read more on this benefit here.

In-hospital

We will pay for these claims in full from your Hospital Benefit if you use a GP that we have a payment arrangement with, as long as their accounts are part of an approved hospital admission.

We pay up to 200% of the Discovery Health Rate (DHR) on Classic plans, and up to 100% of the DHR for Essential plans for GPs that we do not have a payment arrangement with, as long as their accounts are part of an approved hospital admission.

Cover for Specialists

Out-of-hospital

We pay specialist claims up to an agreed rate for specialists we have a payment arrangement with and up to the Discovery Health Rate (DHR) for specialists we don't have a payment arrangement with.

We pay these claims from the available funds in your Medical Savings Account (MSA) or from your Above Threshold Benefit, when you have reached your Annual Threshold.

If you have run out of funds in your Medical Savings Account and have not yet reached your Annual Threshold (you are in the Self-payment Gap), you will need to pay these accounts.

In-hospital

We will pay for these claims in full from your Hospital Benefit if you use a specialist that we have a payment arrangement with, as long as their accounts are part of an approved hospital admission.

We pay up to 200% of the Discovery Health Rate (DHR) on Classic plans, and up to 100% of the DHR for Essential plans for specialists that we do not have a payment arrangement with, as long as their accounts are part of an approved hospital admission.

Cover for Allied, Therapeutic and Psychology

This includes acousticians, biokineticists, chiropractors, counsellors, dieticians, homeopaths, nurses, occupational therapists, physiotherapists, podiatrists, psychologists, psychometrists, social workers, speech and language therapists, and audiologists.

Please refer to the Allied, Therapeutic and Psychology benefit guide for more information.

Out-of-hospital

We pay for out-of-hospital allied, therapeutic and psychology healthcare services from the available funds allocated to your Medical Savings Account and from the Above Threshold Benefit once your claims add up to the Annual Threshold. We pay these claims up to a maximum of 100% of the Discovery Health Rate. If your healthcare provider charges above this rate, you will need to pay the balance.

Claims will add up to, and pay out from, your Above Threshold Benefit at 100% of the Discovery Health Rate once you reach your Annual Threshold.

If you have run out of funds in your Medical Savings Account and have not yet reached your Annual Threshold (you are in the Self-payment Gap), you will need to pay these accounts.

This benefit has a limit and is not a separate benefit. Limits apply to claims paid from your Medical Savings Account, claims paid by you (if you are in a self-payment gap) and claims paid from your Above Threshold Benefit.

In-hospital

We cover these from the Hospital Benefit at 100% of the Discovery Health Rate.

Cover for General Practitioners (GPs)

Out-of-hospital

We pay GP claims from the available funds in your allocated Medical Savings Account.

You also have extended cover through the Day-to-day Extender Benefit (DEB) when you have spent your annual MSA allocation.You can read more on this benefit here.

In-hospital

We will pay for these claims in full from your Hospital Benefit if you use a GP that we have a payment arrangement with, as long as their accounts are part of an approved hospital admission.

We pay up to 200% of the Discovery Health Rate (DHR) on Classic plans, and up to 100% of the DHR for Essential and Coastal plans for GPs that we do not have a payment arrangement with, as long as their accounts are part of an approved hospital admission.

Cover for Specialists

Out-of-hospital

We pay specialist claims from the available funds in your allocated Medical Savings Account.

In-hospital

We will pay for these claims in full from your Hospital Benefit if you use a specialist that we have a payment arrangement with, as long as their accounts are part of an approved hospital admission.

We pay up to 200% of the Discovery Health Rate (DHR) on Classic plans, and up to 100% of the DHR for Essential and Coastal plans for specialists that we do not have a payment arrangement with, as long as their accounts are part of an approved hospital admission.

Cover for Allied, Therapeutic and Psychology

This includes acousticians, biokineticists, chiropractors, counsellors, dieticians, homeopaths, nurses, occupational therapists, physiotherapists, podiatrists, psychologists, psychometrists, social workers, speech and language therapists, and audiologists.

Out-of-hospital

Claims for allied, therapeutic and psychology healthcare professionals are paid from the available funds in the Medical Savings Account. Once you run out of funds you will need to pay for these costs yourself.

In-hospital

We cover these from the Hospital benefit at 100% of the Discovery Health Rate.

Cover for General Practitioners (GPs)

Out-of-hospital

You need to pay for out-of-hospital GP claims

In-hospital

We will pay for these claims in full from your Hospital Benefit if you use a GP that we have a payment arrangement with, as long as their accounts are part of an approved hospital admission.

We pay up to 200% of the Discovery Health Rate (DHR) on Classic plans, and up to 100% of the DHR for Essential and Coastal plans for GPs that we do not have a payment arrangement with, as long as their accounts are part of an approved hospital admission.

Cover for Specialists

Out-of-hospital

You need to pay for out-of-hospital specialist claims

In-hospital

We will pay for these claims in full from your Hospital Benefit if you use a specialist that we have a payment arrangement with, as long as their accounts are part of an approved hospital admission.

We pay up to 200% of the Discovery Health Rate (DHR) on Classic plans, and up to 100% of the DHR for Essential and Coastal plans for specialists that we do not have a payment arrangement with, as long as their accounts are part of an approved hospital admission.

Cover for Allied, Therapeutic and Psychology

This includes acousticians, biokineticists, chiropractors, counsellors, dieticians, homeopaths, nurses, occupational therapists, physiotherapists, podiatrists, psychologists, psychometrists, social workers, speech and language therapists, and audiologists.

Out-of-hospital

These plans do not cover claims for allied, therapeutic and psychology healthcare professionals. You are responsible for payment.

In-hospital

We cover these from the Hospital benefit at 100% of the Discovery Health Rate.

Cover for General Practitioners (GPs)

Out-of-hospital

You pay R55 on Classic and R110 on Essential of the consultation fee with the balance of this fee covered at 100% of the Discovery Health Rate (DHR).

Video consultations with your Smart network GP are covered in full up to the DHR.

You need to visit a Smart Network GP

In-hospital

We will pay for these claims in full from your Hospital Benefit if you use a GP that we have a payment arrangement with, as long as their accounts are part of an approved hospital admission.

We pay up to 200% of the Discovery Health Rate (DHR) on Classic, and up to 100% of the DHR on Essential for GPs that we do not have a payment arrangement with, as long as their accounts are part of an approved hospital admission.

Cover for Specialists

Out-of-hospital

You need to pay for out-of-hospital specialist claims.

In-hospital

We will pay for these claims in full from your Hospital Benefit if you use a specialist that we have a payment arrangement with, as long as their accounts are part of an approved hospital admission.

We pay up to 200% of the Discovery Health Rate (DHR) on Classic, and up to 100% of the DHR for Essential for specialists that we do not have a payment arrangement with, as long as their accounts are part of an approved hospital admission.

Cover for Allied, Therapeutic and Psychology

This includes acousticians, biokineticists, chiropractors, counsellors, dieticians, homeopaths, nurses, occupational therapists, physiotherapists, podiatrists, psychologists, psychometrists, social workers, speech and language therapists, and audiologists.

Out-of-hospital

These plans do not cover claims for allied, therapeutic and psychology healthcare professionals. You are responsible for payment.

In-hospital

We cover these from the Hospital benefit at 100% of the Discovery Health Rate.

Cover for General Practitioners (GPs)

Out-of-hospital

You have unlimited cover for medically appropriate GP consultations. When joining, you must choose a GP from the KeyCare or KeyCare Start GP network, depending on the plan you choose. You must go to your chosen GP for us to cover your consultations, including some minor procedures. Preauthorisation is required after your 15th GP visit.

On KeyCare Plus, if you need to see a doctor and your chosen GP is not available, each person on your plan can go to any GP for an out-of- network visit. On KeyCare Start you can go to any KeyCare Network GP for an out-of-network visit. Out-of-network GP visits are limited to four visits per person on KeyCare Plus and two per person on KeyCare Start each year, covered up to the DHR, depending on the plan you choose. We will cover the GP visit, selected blood tests and X-rays, and medicine on our medicine list.

The KeyCare Core plan does not offer day-to-day benefits. You need to pay for out-of-hospital GP claims yourself.

In-hospital

We will pay for these claims in full from your Hospital Benefit if you use a GP that we have a payment arrangement with, as long as their accounts are part of an approved hospital admission.

We pay up to 100% of the Discovery Health Rate (DHR) for GPs that we do not have a payment arrangement with, as long as their accounts are part of an approved hospital admission.

Cover for Specialists

Out-of-hospital

You have specialist cover up to R4 400 on KeyCare Plus and KeyCare Core, and up to two visits up to R2 200 on KeyCare Start per person per year. Your chosen GP must refer you to a specialist and you need a reference number from us before your consultation with the specialist. On KeyCare Plus, if you need to see a maxillo-facial surgeon, periodontist, ophthalmologist or a specialist for maternity care, you do not need a referral from your GP or a reference number from us. Out-of-hospital MRI and CT scans are paid up to the Specialist Benefit Limit.

Cover depends on the plan you choose.

In-hospital

We will pay for these claims in full from your Hospital Benefit if you use a specialist that we have a payment arrangement with, as long as their accounts are part of an approved hospital admission.

We pay up to 100% of the Discovery Health Rate (DHR) for specialists that we do not have a payment arrangement with, as long as their accounts are part of an approved hospital admission.

Cover for Allied, Therapeutic and Psychology

This includes acousticians, biokineticists, chiropractors, counsellors, dieticians, homeopaths, nurses, occupational therapists, physiotherapists, podiatrists, psychologists, psychometrists, social workers, speech and language therapists, and audiologists.

Out-of-hospital

These plans do not cover claims for allied, therapeutic and psychology healthcare professionals. You are responsible for payment.

In-hospital

We cover these from the Hospital benefit at 100% of the Discovery Health Rate.

 
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