KeyCare Series 2014 The benefts explained in this brochure are provided by Discovery Health Medical Scheme, registraton number 1125, administered by Discovery Health (Pty) Ltd, registraton number 1997/013480/07, an authorised fnancial services provider. This brochure is only a summary of the key benefts and features of Discovery Health Medical Scheme plans, awaitng formal approval from the Council for Medical Schemes. When reference is made our or we in the context of benefts, members, payments or cover, in this brochure these are references to Discovery Health Medical Scheme. For compliance questons, email compliance@discovery.co.za. Vitality is not part of Discovery Health Medical Scheme. Vitality is a separate product sold and administered by Discovery Vitality (Pty) Ltd. Registraton number 1999/007736/07, an authorised fnancial services provider. MedSaver and ChroniCare are brought to you by Discovery Vitality. YOUR HEALTHCARE COVER IN 2014 Our aim is to keep you healthy and provide you with the best of care when you need it most. We design our integrated product solutons to make sure you get the most value from your health plan, and to assist you in avoiding out-of-pocket payments wherever possible, especially when you or your loved ones experience a critcal illness or major hospital admission. This integrated approach to your healthcare is made possible by the combined power of Discovery Health Medical Scheme and Discovery Health as well as Discovery Vitality. Discovery Health Medical Scheme ofers the widest range of health plans in the market. It is South Africas largest open medical scheme with over 2,5 million members and more than 50% share of the local open medical schemes market. Discovery Health is the administrator of Discovery Health Medical Scheme, responsible for many functons, including claims processing and payment, and client service touch points such as the website and call centre. Vitality is a separate Discovery company that ofers a wellness programme that you may choose to join as a Discovery Health Medical Scheme member. Vitalitys ability to make people healthier and give them great rewards has made it the worlds leading wellness programme, with over fve million members on four contnents. This guide gives you a summary of the KeyCare Series benefts. You will also fnd informaton about the additonal benefts and tools provided by Discovery Health. Please familiarise yourself with the informaton we have provided, so you can make the best choices when it comes to your healthcare. Regards Milton Streak Principal Ofcer: Discovery Health Medical Scheme Dr Jonathan Broomberg CEO: Discovery Health Stay in touch with us Discovery Vitality (Pty) Ltd is an authorised fnancial services provider. Registraton number: 1999/007736/07. www.discovery.co.za facebook.com/discoveryhealthsa twiter.com/discovery_sa Dear Member Thank you for giving us the opportunity to look afer your healthcare cover needs 4 KEYCARE SERIES PRODUCT PLATFORM Discovery Health Medical Scheme ofers a range of optons to cater for every need. The KeyCare Series ofers afordable cover at KeyCares networks of hospitals and doctors. Hospital cover KeyCare Plans ofer cover in a defned network of hospitals. On KeyCare Core and KeyCare Plus, we cover you in any private hospital for emergencies and planned hospital admissions that you have authorised with us in the KeyCare network of hospitals. On KeyCare Access, we cover emergencies and trauma in the Keycare Access Hospital and KeyCare Hospital networks of private hospitals. We cover childbirth and care for your baby up to 12 months in the KeyCare Access Hospital Network, and all other hospital care is covered in our contracted network of state facilites. Chronic illness cover You have cover for a list of 27 conditons on our Chronic Disease List, as long as your chronic medicine is on the KeyCare medicine list. You need to get your approved medicine from one of our approved pharmacies or your chosen KeyCare GP (if they dispense medicine). Screening and preventon The Screening and Preventon Beneft covers blood glucose, blood pressure, cholesterol and body mass index measurements at a Discovery Wellness Network provider. The beneft also pays for a mammogram, Pap smear, PSA (prostate screening test) and HIV screening tests. If you are 65 years or older or are registered for certain chronic conditons, we also cover a seasonal fu vaccine. Screening and preventon KeyFIT Day-to-day medical care Chronic Illness Beneft Planned hospital care Critcal hospital care 5 Discovery Vitality ofers the worlds leading science-based programme with a personalised approach to wellness Vitality helps you get healthier by giving you the knowledge, tools and motvaton to improve your health its been clinically proven that engaged Vitality members are healthier, live longer and have lower healthcare costs. Members on KeyCare Plus and KeyCare Access have cover for day-to-day healthcare such as GP visits, basic x-rays, blood, urine, other fuid and tssue tests, medicine, dentstry and cover for eye care. Day-to-day cover Discovery Vitality (Pty) Ltd is an authorised fnancial services provider. Registraton number: 1999/007736/07. 6 THE FULL COVER CHOICE Our extensive networks of healthcare providers, combined with our unique self-service tools, mean you can avoid co-payments. These tps will guide you to full cover. Remember to look out for the full cover stamp throughout this guide. Use our extensive hospital networks You are covered in full when you use a network hospital. Use our MaPS tool to fnd a hospital in our network. 1 Use a GP or specialist who we have a payment arrangement with We ofer the broadest range of GP and specialist payment arrangements, which provides full cover both in hospital and out of hospital. Use our MaPS tool to fnd a healthcare professional who we have a payment arrangement with. 2 You can access MaPS and MedXpress at www.discovery.co.za or on the Discovery app. 7 Screening and preventon KeyFIT Day-to-day medical care Chronic Illness Beneft Planned hospital care Critcal hospital care Go for preventve screening tests We cover preventve screening tests such as mammograms, blood pressure and cholesterol tests which are great at detectng early warning signs of serious illness. Having these tests done helps you to stay healthy, because preventon is beter than cure. 4 Use our preferred medicine All Discovery Health Medical Scheme plans ofer a comprehensive list of medicine which we cover in full. Use Discovery MedXpress or ask your pharmacist about your optons to avoid a co-payment. If you choose medicine not on our medicine list, you will have to pay for it. 3 Discovery Vitality (Pty) Ltd is an authorised fnancial services provider. Registraton number: 1999/007736/07. 8 IMPORTANT CONCEPTS TO HELP YOU UNDERSTAND YOUR HEALTH PLAN Use these handy defnitons to help you understand important concepts discussed in this guide. Discovery Health Rate This is a rate set by Discovery Health Medical Scheme at which claims and services for healthcare providers (hospitals, pharmacies and healthcare professionals) will be paid. DHR Chronic Illness Beneft (CIB) You have cover for a list of 27 conditons on our Chronic Disease List, as long as your chronic medicine is on the KeyCare medicine list. The Chronic Disease List (CDL) is a defned list of chronic conditons we cover according to the Prescribed Minimum Benefts. You need to get your approved chronic medicine from one of our network pharmacies or from your chosen KeyCare GP (if he or she dispenses medicine). You have full cover for approved medicine on the Schemes medicine list (formulary). If you choose chronic medicine that is not on our medicine list, you will have to pay for it. Hospital cover We cover you in hospital for emergency and planned hospital admissions. You have to get authorisaton from us 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 treatng doctor, anaesthetst and any other approved healthcare services like pathology or radiology. Day-to-day cover Day-to-day cover includes your visits to doctors out of hospital, blood tests and medicines purchased for everyday use. Members on KeyCare Plus and KeyCare Access have cover for day-to-day medical care. 9 Networks Some plans, benefts and healthcare services require you to use the Schemes network providers. If you use these providers we are able to keep your contributons as afordable as possible while ensuring full cover. Medicine list (formulary) 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 conditons to ensure you always have an opton of full cover. Payment arrangements The Scheme has entered into payment arrangements with various healthcare professionals that have agreed to be reimbursed at the Discovery Health Rate. This ensures that you have no co-payments. Limits Most in- and out-of-hospital healthcare benefts are unlimited but there are some healthcare services that are subject to annual limits. It is important for you to familiarise yourself with these limits and to track your usage by logging onto www.discovery.co.za or checking your statements. 10 IMPORTANT CONCEPTS TO HELP YOU UNDERSTAND YOUR HEALTH PLAN Claiming for healthcare afer a motor vehicle accident Discovery Health Medical Scheme pays for your healthcare expenses when youre involved in a motor vehicle accident according to your selected health plan and rules of the Scheme. According to the rules of Discovery Health Medical Scheme, you need to lodge a claim with the Road Accident Fund. If your claim with the Road Accident Fund is successful and both Discovery Health Medical Scheme and the Road Accident Fund pay your medical expenses, youll need to pay back the medical expenses paid by the Road Accident Fund to Discovery Health Medical Scheme. Claiming for healthcare afer an injury on duty Discovery Health Medical Scheme pays for your healthcare expenses related to an injury on duty at your workplace in accordance with the rules of the Scheme and your plan type. According to the Compensaton for Occupatonal Injuries and Diseases Act, 1993, the Compensaton Commissioner must pay for any treatment related to an injury on duty. All accidents or alleged accidents at work that entail medical expenses or absence from work for more than three days, or both, must be reported within seven days to the Compensaton Commissioner. Discovery Health will help you with any questons and free administraton of your injury on duty claim. If your claim with the Compensaton Commissioner is successful and both Discovery Health Medical Scheme and the Compensaton Commissioner pay your accident-related medical expenses youll need to pay your medical expenses paid by the Compensaton Commissioner to Discovery Health Medical Scheme. For any assistance with injury on duty claims, please contact Discovery Health Third Party Recovery Services on 011 529 5096/1419/3929. 11 What Prescribed Minimum Beneft (PMB) conditons are These are conditons 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 agreement with Discovery Health Medical Scheme to provide treatment or services at a contracted rate and without any co-payments by you. Cover for Prescribed Minimum Benefts In most cases, Discovery Health Medical Scheme plans ofer benefts that are far richer than the Prescribed Minimum Benefts. To access Prescribed Minimum Benefts, there are rules that apply: Your medical conditon must qualify for cover and be part of the list of defned Prescribed Minimum Beneft conditons The treatment needed must match the treatments in the defned benefts You must use Designated Service Providers in the Discovery Health network. This does not apply in life-threatening emergencies. However even in these cases, where appropriate and according to the rules of the Scheme, you may be transferred to a healthcare provider in the Discovery Health network otherwise we will pay up to 80% of the Discovery Health Rate. You will be responsible for the diference between what we pay and the actual cost of your treatment. More informaton on our approach to Prescribed Minimum Benefts is available on www.discovery.co.za PRESCRIBED MINIMUM BENEFITS 12 Plus | Access | Core KeyCare Series Plan range KEY FEATURES Screening and preventon KeyFIT Day-to-day medical care Chronic Illness Beneft Planned hospital care Critcal hospital care Unlimited hospital cover in our KeyCare network of hospitals Guaranteed full cover in hospital for specialists on the KeyCare network, and up to 100% of the Discovery Health Rate for other healthcare professionals Essental cover for chronic medicine on the KeyCare medicine list for all CDL chronic conditons Unlimited cover for medically appropriate GP consultatons, blood tests, x-rays or medicine in our KeyCare network on the KeyCare Plus and KeyCare Access Plans Discovery Vitality (Pty) Ltd is an authorised fnancial services provider. Registraton number: 1999/007736/07. 13 PLAN SPECIFIC INFORMATION KeyCare Series Plan range The KeyCare Series has three health plan types. These are: KeyCare Plus KeyCare Access KeyCare Core There are slight diferences in benefts as highlighted on the next page. The benefts not mentoned in the table are the same across both plans. 14 PLAN SPECIFIC INFORMATION KeyCare Plus KeyCare Access KeyCare Core Hospitals Unlimited cover in the KeyCare Hospital Network. There is a list of procedures that are covered in the KeyCare day surgery network. Unlimited cover for emergencies, trauma, childbirth and care for your newborn in the KeyCare Access network of private hospitals. Other conditons are covered in a contracted network of state facilites. Unlimited cover in the KeyCare Hospital Network. There is a list of procedures that are covered in the KeyCare day surgery network. Day-to-day medical cover Primary care cover through your chosen GP and day-to-day medicine from our medicine list. This plan does not ofer day-to-day medical cover. Private specialist cover up to a limit of R2 750 for each person. Private specialist cover up to a limit for emergencies, trauma, childbirth and cover for your baby up to 12 months afer childbirth. Private specialist cover up to a limit of R2 750 for each person. KeyCare plans ofer you the best and most afordable cover through the KeyCare network of hospitals and doctors. The KeyCare Series has three health plan types; there are slight diferences in the beneft structure as highlighted below. The benefts not mentoned in the below table and on the next page are the same across all plans. 15 PLAN SPECIFIC INFORMATION KeyCare Plus KeyCare Access KeyCare Core Casualty visits Cover in any casualty unit at one of the KeyCare network hospitals. You have to pay the frst R225 of the consultaton. Other than for emergencies and trauma, you have cover in any casualty unit at one of the KeyCare Access Hospitals and KeyCare network hospitals once a year. You have to pay the frst R225 of the consultaton. Casualty visits are not covered. Chronic medicines prescriptons Your chosen KeyCare GP must prescribe your approved chronic medicine. Any GP can prescribe your approved medicine. Cancer We cover treatment if it is a Prescribed Minimum Beneft and if you go to a cancer specialist in our network. We cover treatment if it is a Prescribed Minimum Beneft in a state facility. We cover treatment if it is a Prescribed Minimum Beneft and if you go to a cancer specialist in our network. Trauma Recovery Extender Beneft Out-of-hospital claims for recovery afer certain traumatc events are covered on this beneft for the rest of the year in which the trauma took place, and a year afer the trauma. This plan does not ofer this beneft. 16 Always keep your membership card with you; it identfes you as a KeyCare member. Your membership card helps you get access to your benefts. Always use your chosen GP or a hospital in the KeyCare network. Check with your GP that your treatment or medicine is on our list of covered services. If your GP decides you have to see a specialist, your GP will get approval from us so that you can go to the specialist. Make sure you take the reference number with you when you visit the specialist. In an emergency, go straight to hospital. If you are going to hospital for a planned procedure, call us to confrm your benefts before you are admited. This way, you will always know what you are covered for. WHAT TO DO TO GET THE MOST OUT OF YOUR KEYCARE PLAN 17 Cover in hospital the best of care 18 Medical emergency A medical emergency is the sudden and, at the tme, unexpected onset of a health conditon that needs immediate medical or surgical treatment, where failure to provide medical or surgical treatment would result in serious impairment to bodily functons or serious dysfuncton of a bodily organ or part, or would place the persons life in serious jeopardy in line with the Schemes rules and Medical Schemes Act. What to do in a medical emergency In an emergency, go straight to hospital. If you need medically equipped transport, call 0860 999 911. This line is managed by highly qualifed emergency personnel who will send air or road emergency evacuaton transport to you, depending on which is most appropriate. Your hospital cover is made up of: Cover for the account of your hospital stay Cover for the accounts from your admitng doctor, anaesthetst or any other approved healthcare professional. Cover for your hospital account on KeyCare Core and KeyCare Plus We cover you in any hospital in the KeyCare network of hospitals. If you dont go to a KeyCare network hospital for planned admissions, you will have to pay the claims yourself. We cover these procedures in our day surgery network: Adenoidectomy Arthrocentesis (joint injecton) Cataract surgery Cautery of vulva warts Circumcision Colonoscopy Cystourethroscopy Diagnostc D&C Gastroscopy Hysteroscopy Myringotomy Myringotomy with intubaton (grommets) Prostate biopsy Proctoscopy Removal of pins and plates Sigmoidoscopy Simple abdominal hernia repair Simple nasal procedure for nose bleeding (that is, nasal plugging and nasal cautery) Tonsillectomy Treatment of Bartholins cyst/abscess Vasectomy Vulva/cone biopsy HOSPITAL COVER There is no overall hospital limit. If you have to stay in hospital for a long tme, or if your treatment is very expensive, your cover wont run out. Some healthcare services and procedures have a limit or we may have rules on how we pay for them. 19 Cover for your hospital account on KeyCare Access On KeyCare Access, healthcare services for approved admissions for emergencies, trauma, childbirth and care for your baby up to 12 months afer childbirth are covered in our network of private hospitals with no overall limit. We pay approved admissions for all other hospital care in our network of state facilites. We cover the following traumas in our network of private hospitals Injuries at work Burns Injuries from a crime Sexual assault Injuries from a car accident Injuries from a fall The loss of an arm, hand, leg or foot Near drowning Head injuries Poisoning or a serious allergic reacton that may cause death Care for your baby afer childbirth on KeyCare Access This beneft covers babies that are registered on the Scheme from their date of birth when born to a parent registered on the Scheme. It covers approved hospital admissions in our network of private hospitals for the baby for 12 months from the babys date of birth. Babies not added to the Scheme from their date of birth will be covered in our contracted network of state facilites. Cover for related accounts We guarantee full cover when you use specialists and healthcare professionals on the KeyCare network. Other specialists and healthcare professionals If you are treated by a specialist who we dont have an arrangement with and other healthcare professionals, we pay up to 100% of the Discovery Health Rate. If the healthcare professional charges more than the Discovery Health Rate, you must pay the rest. HOSPITAL COVER 20 Cover for going to casualty If you are admited to hospital from casualty, we will cover the costs of the casualty visit from your Hospital Beneft, as long as we confrm your hospital admission. On KeyCare Plus, you can go to any casualty unit at one of the KeyCare network hospitals. You have to pay the frst R225 of the casualty account if you are not admited to hospital from casualty. For emergencies and trauma on KeyCare Access, you can go to any casualty unit at one of the KeyCare Access or KeyCare network hospitals. For visits, other than emergencies and trauma on KeyCare Access, each person can go to casualty at one of the KeyCare network hospitals once a year. You have to pay the frst R225 of the casualty account if you are not admited. Your cover for MRI and CT scans MRI and CT scans are like x-rays, but show much more detail. They are used when an x-ray doesnt show enough. If your scan is related to an approved hospital stay in our network of private hospitals, we pay for it from your Hospital Beneft. If it is not, we pay for it from your Specialist Beneft, up to R2 750 for each person. We do not pay for MRI or CT scans that are related to conservatve back or neck treatment (this is treatment for your back or neck that is not surgery). Unlimited healthcare services Most of your in-hospital healthcare services have no overall limit. These are: GPs Specialists Allied healthcare professionals, like physiotherapists Pathology and radiology 21 HOSPITAL COVER Some healthcare services have an annual limit KeyCare Core and KeyCare Plus KeyCare Access Mental health 21 days for each person 21 days for each person covered in our contracted network of state facilites. Alcohol and drug rehabilitaton 21 days for each person 21 days for each person covered in our contracted network of state facilites. Cataract surgery We cover cataract surgery as long as we have approved your treatment at a doctor and facility in our network for cataract surgery. Covered in our contracted network of state facilites. Chronic dialysis We cover these expenses in full as long as we have approved your treatment at a doctor and facility in our network. We cover these expenses in full as long as we have approved your treatment at a doctor and facility in the KeyCare Access Network. Compassionate care R28 500 for each person in their lifetme 22 HOSPITAL NETWORKS KEYCARE HOSPITAL NETWORKS You must go to one of these hospitals for planned hospital admissions. If you do not use one of these hospitals for a planned admission, you will need to pay your claims. KeyCare Core and KeyCare Plus Hospital Network KeyCare Access trauma and emergency network Eastern Cape East London Life Beacon Bay Hospital Life East London Private Hospital Life St James Operatng Theatres Life St Dominics Private Hospital Humansdorp Life Isivivana Private Hospital Port Elizabeth Life New Mercantle Hospital Queenstown Life Queenstown Private Hospital Uitenhage Netcare Cuyler Clinic Umtata Life St Marys Private Hospital Free State Bethlehem Hoogland Medi-Clinic Bloemfontein Bloemfontein Eye Centre Netcare Pelonomi Private Hospital Life Rosepark Clinic Life Pasteur Hospital Netcare Universitas Private Hospital Welkom Ernest Oppenheimer Hospital Welkom Medi-Clinic St Helena Hospital Gauteng Benoni Life The Glynwood Hospital Boksburg Botshelong Empilweni Clinic (Clinix Vosloorus) Sunshine Hospital Brakpan Life Dalview Clinic Germiston Life Roseacres Clinic Heidelberg Life Suikerbosrand Clinic Johannesburg Netcare Rand Clinic Johannesburg Eye Clinic Netcare Garden City Clinic Life Brenthurst Clinic Kempton Park Arwyp Medical Centre Lakefeld Netcare Optklin Eye Hospital Lenasia Lenmed Clinic Midrand Life Carstenhof Clinic Pretoria Netcare Bougainville Private Hospital Centurion Eye Hospital Life Eugene Marais Hospital Netcare Jakaranda Hospital Legae Medi-Clinic Louis Pasteur Hospital Medforum Medi-Clinic Muelmed Hospital Pretoria Eye Insttute Zuid-Afrikaans Hospital Randfontein Life Robinson Hospital Lenmed Randfontein Private Hospital Sasolburg Netcare Vaalpark Hospital Soweto Clinix Private Hospital Tshepo Themba Clinix Private Hospital Lesedi Springs Life Springs Parkland Clinic Life St Marys Womens Clinic Thembisa Zamokuhle Private Hospital Vanderbijlpark Emfuleni Medi-Clinic Ocumed Vereeniging Clinix Private Hospital Sebokeng Midvaal Private Hospital Westgate Medgate Day Clinic KwaZulu-Natal Amanzimtot Netcare Kingsway Hospital Chatsworth Life Chatsmed Garden Hospital Durban Life City Hospital Life Entabeni Hospital Empangeni Life Empangeni Garden Clinic Isipingo Life Isipingo Clinic On KeyCare Access we pay approved admissions for hospital care other than emergencies, trauma, childbirth and care for your baby in a contracted state facilites. 23 HOSPITAL NETWORKS KEYCARE HOSPITAL NETWORKS Kokstad Kokstad Private Hospital Ladysmith La Verna Hospital Newcastle Newcastle Private Hospital Phoenix Life Mount Edgecombe Pietermaritzburg Midlands Medical Centre Netcare St Annes Hospital Pinetown Life Crompton Hospital Port Shepstone Hibiscus Hospital Richards Bay Netcare The Bay Hospital Sydenham Nu Shifa Hospital Tongaat Victoria Private Hospital (Tongaat) Limpopo Bela-Bela St Vincents Hospital Phalaborwa Clinix Phalaborwa Private Hospital Polokwane Limpopo Medi-Clinic Thabazimbi Thabazimbi Medi-Clinic Tzaneen Tzaneen Medi-Clinic Mpumalanga Barberton Barberton Medi-Clinic Emalahleni Life Cosmos Hospital Emalahleni Day Hospital Ermelo Ermelo Private Hospital Middelburg Life Middelburg Private Hospital Nelspruit Nelspruit Private Hospital Trichardt Highveld Medi-Clinic North West Carletonville Leslie Williams Private Hospital Western Deep Clinic Klerksdorp Life Anncron Clinic Mafkeng Victoria Private Hospital (Mafkeng Hospital) Orkney West Vaal Clinic Potchefstroom Potchefstroom Medi-Clinic Rustenburg Life Peglerae Hospital Northern Cape Kathu Kathu Medi-Clinic Kimberley Kimberley Medi-Clinic Upington Upington Private Hospital Vryburg Vryburg Private Hospital Western Cape Bellville Bellville Medical Centre Louis Leipoldt Medi-Clinic Cape Town Netcare Christaan Barnard Memorial Hospital Netcare UCT Medical Centre Ceres Ceres Private Hospital Gatesville Gatesville Medical Centre George Geneva Clinic George Medi-Clinic Hermanus Hermanus Medi-Clinic Kuils River Netcare Kuils River Private Hospital Milnerton Milnerton Medi-Clinic Mitchells Plain Mitchells Plain Medical Centre Mossel Bay Bayview Hospital Oudtshoorn Cango Day Clinic Klein Karoo Medi-Clinic Paarl Paarl Medi-Clinic West Coast Life West Coast Private Hospital Worcester Worcester Medi-Clinic Lesotho Willies Hospital On KeyCare Access we pay approved admissions for hospital care other than emergencies, trauma, childbirth and care for your baby in a contracted state facilites. 24 HOSPITAL NETWORKS KEYCARE HOSPITAL NETWORKS Eastern Cape Kokstad Netcare Kokstad Hospital Port Elizabeth Life New Mercantle Hospital Uitenhage Netcare Uitenhage Hospital Umtata Life St Marys Private Hospital Free State Bloemfontein Netcare Pelonomi Private Hospital Gauteng Alberton Netcare Clinton Hospital Johannesburg Netcare Rand Clinic Krugersdorp Netcare Krugersdorp Hospital Pretoria Netcare Femina Hospital Legae Medi-Clinic Louis Pasteur Hospital Sasolburg Netcare Vaalpark Hospital Soweto Clinix Private Hospital Lesedi Springs Netcare N17 Hospital Tembisa Zamokhule Private Hospital Kwazulu-Natal Amanzimtot Netcare Kingsway Hospital Ladysmith La Verna Hospital Pietermaritzburg Netcare St Annes Hospital Richards Bay Netcare The Bay Hospital Tongaat Victoria Private Hospital (Tongaat) Limpopo Phalaborwa Clinix Phalaborwa Private Hospital Polokwane Limpopo Medi-Clinic Tzaneen Tzaneen Medi-Clinic Mpumulanga Nelspruit Nelspruit Medi-Clinic North West Rustenburg Netcare Ferncrest Hospital Western Cape Gatesville Gatesville Medical Centre Kuils River Netcare Kuils River Private Hospital Milnerton Milnerton Medi-Clinic Mitchells Plain Mitchells Plain Medical Centre Paarl Paarl Medi-Clinic Northern Cape Kimberley Kimberley Medi-Clinic KeyCare Access Hospital Network for childbirth and care for your baby On KeyCare Access we pay approved admissions for hospital care other than emergencies, trauma, childbirth and care for your baby in a contracted state facilites. 25 Cover for chronic illness, cancer and HIV the best of care 26 CHRONIC ILLNESS, CANCER AND HIV COVER Your cover for chronic conditons You have cover for a list of chronic conditons, as long as your chronic medicine is on the KeyCare medicine list. We need to approve your applicaton before we cover your conditon from the Chronic Illness Beneft. On the KeyCare Plus and KeyCare Access Plans, your chosen KeyCare GP must prescribe your approved chronic medicine. On the KeyCare Core Plan, any GP can prescribe your approved medicine. How we pay for medicine You need to get your approved chronic medicine that is on the KeyCare medicine list from one of our network pharmacies or from your chosen KeyCare GP (if he or she dispenses medicine). If you get your medicine from anywhere else, you will have to pay 20% of the Discovery Health Rate for medicines. If you use chronic medicine that is not on our medicine list, you will have to pay for it yourself. Cover for cancer We cover you for cancer treatment on the DiscoveryCare Oncology Programme. If youre diagnosed with cancer you need to register for the programme. On the KeyCare Core and KeyCare Plus Plans, we cover cancer treatment if it is a Prescribed Minimum Beneft and if you go to a cancer specialist in our network. On KeyCare Access, we cover cancer treatment if it is a Prescribed Minimum Beneft in a state facility. Cover for HIV and AIDS When you register for our HIVCare Programme you are covered for the all-inclusive care that you need. You get access to clinically sound and cost-efectve treatment and you can be assured of confdentality at all tmes. We cover four GP consultatons, a specialist visit, blood tests, scans and x-rays at a network provider. Approved medicines on our medicine list are covered in full. You need to get your medicine from a Designated Service Provider to avoid a 20% co-payment. 27 Cover for day-to-day medical expenses the best of care 28 DAY-TO-DAY COVER Cover for GP visits When joining, you must choose a GP from the KeyCare GP network. You must go to your chosen GP for us to cover your consultatons and some minor procedures. Blood, urine and other fuid and tssue tests We pay for a list of blood, urine and other fuid and tssue tests. Your chosen GP must ask for these tests by flling in a KeyCare pathology form. Day-to-day medicine We pay for medicines from our medicine list if they are prescribed by your chosen KeyCare network GP. You get one out-of-network GP visit If you need to see a doctor and your chosen GP from our network is not available for you to see, each person on your membership can go to any other GP once a year. We will cover the GP visit, with selected blood tests and x-rays and medicines on our medicine list. Cover for dentstry We cover consultatons, fllings and tooth removals at a dentst in our dentst network. Cover for eye care We cover one eye test for each person, but you must go to an eye doctor in our network. The eye doctor will have a specifc range of glasses that you can choose from. You can get a set of contact lenses instead of glasses if you choose to. You can get new glasses or contact lenses every 24 months. Applicable to KeyCare Plus and KeyCare Access Plans 29 Basic x-rays We pay for a list of basic x-rays at a network provider. Your chosen GP must ask for the x-rays to be done. Casualty visits On KeyCare Plus you can go to any casualty unit at one of the KeyCare network hospitals. You have to pay the frst R225 of the consultaton. On KeyCare Access, other than for emergencies and trauma, each person can go to casualty at one of the KeyCare network hospitals once a year. You have to pay the frst R225 of the consultaton. You dont need to call us if you go to casualty. Trauma Recovery Extender Beneft We will cover specifc out-of-hospital claims for your recovery afer certain traumatc events. Well cover you for the rest of the year in which the trauma took place, and in the year afer your trauma. You may need to apply for this beneft. This doesnt apply to KeyCare Core. Medical equipment We cover wheelchairs, wheelchair bateries 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. There is an overall limit of R4 450 for each family. Other types of healthcare professionals We do not cover other types of healthcare professionals, such as physiotherapists, psychologists, speech therapists, audiologists, homeopaths or chiropractors from your day-to-day benefts. DAY-TO-DAY COVER 30 Specialist Beneft Each person is covered up to R2 750. Your GP must get a reference number before your consultaton with the specialist. If you need to see a dental specialist, eye specialist (opthalmologist) or a specialist for maternity care, you do not need a referral from your GP or a reference number from us. The KeyCare Access Plan covers specialist visits in our network for maternity, care for your baby up to 12 months, trauma and emergencies up to the limit. You have to register your baby as soon as it is born. For all other healthcare services we cover specialists employed by a state facility. Preventve screening The Screening and Preventon Beneft covers certain tests like blood glucose, blood pressure, cholesterol and body mass index when done at any one of the Discovery Wellness Network providers. We also cover a mammogram, Pap smear, PSA (a prostate screening) and HIV screening tests. Members 65 years or older and members registered for certain chronic conditons are also covered for a seasonal fu vaccine. Antenatal Beneft If you are pregnant, the Antenatal Beneft covers you at 100% of the Discovery Health Rate for the following healthcare services: Four visits to a midwife or gynaecologist/obstetrician One routne scan (between 10 and 20 weeks) Selected blood tests requested by your gynaecologist/obstetrician BENEFITS THAT ENHANCE YOUR COVER 31 GENERAL EXCLUSIONS Discovery Health Medical Scheme has certain exclusions. We do not pay for healthcare services related to the following, except where stpulated as part of a defned beneft or under the Prescribed Minimum Benefts. General exclusion list Cosmetc procedures and treatments Otoplasty for bat ears, port-wine stains and blepharoplasty (eyelid surgery) Breast reductons or enlargements and gynaecomasta Obesity Frail care Infertlity Wilfully self-inficted illness or injury Alcohol, drug or solvent abuse Wilful and material violaton of the law Wilful partcipaton in war, terrorist actvity, riot, civil commoton, rebellion or uprising Injuries sustained or healthcare services arising during travel to or in a country at war Experimental, unproven or unregistered treatments or practces Search and rescue Any costs for which a third party is legally responsible We also do not cover the complicatons or the direct or indirect expenses that arise from any of the exclusions listed above, except where stpulated as part of a defned beneft or under the Prescribed Minimum Benefts. Waitng periods If we apply waitng periods because members have never belonged to a medical scheme or have had a break in membership of more than 90 days before joining Discovery Health Medical Scheme, they will not have access to the Prescribed Minimum Benefts during their waitng periods. This includes cover for emergency admissions. 32 KEYCARE SERIES EXCLUSIONS In additon to the general exclusions that apply to all plans, the KeyCare Series does not cover the following, except if the Prescribed Minimum Benefts say schemes must: 1. Hospital admissions related to: Dentstry Nail disorders Skin disorders Investgatons and diagnostc work-up Functonal nasal surgery Electve caesarean secton, except if medically necessary Surgery for oesophageal refux and hiatus hernia Back and neck treatment or surgery Joint replacements, including but not limited to hips, knees, shoulders and elbows Cochlear implants, auditory brain implants and internal nerve stmulators this includes procedures, devices and processors Healthcare services that should be done out of hospital and for which an admission to hospital is not necessary 2. Correcton of Hallux Valgus/Bunion and Tailors Bunion/Bunionete 3. Arthroscopy 4. Removal of varicose veins 5. Refractve eye surgery 6. Non-cancerous breast conditons 7. Healthcare services outside South Africa We also do not cover the cost of treatment for any complicatons or the direct or indirect expenses related to any of these excluded conditons and treatments. The benefts outlined in this guide are a summary of the plans registered in the medical scheme rules. These benefts are reviewed annually and amended in line with the requirements of the Medical Schemes Act and also take into account the requirements of the Consumer Protecton Act where it relates to the business of a medical scheme. 33 CONTRIBUTIONS Total contributons Main member Adult Child* KeyCare Plus (8 801+) R1 448 R1 448 R388 KeyCare Plus (6 651-8 800) R973 R973 R272 KeyCare Plus (0-6 650) R695 R695 R251 KeyCare Access (8 801+) R1 416 R1 416 R381 KeyCare Access (6 651- 8 800) R942 R942 R267 KeyCare Access (4 151-6 650) R653 R653 R235 KeyCare Access (0-4 150) R490 R490 R212 KeyCare Core (8 801+) R1 070 R1 070 R241 KeyCare Core (6 651-8 800) R693 R693 R171 KeyCare Core (0-6 650) R556 R556 R143 * We count a maximum of three children when we work out the monthly contributons. 34 CLAIMING Submitng proof of claims payment Discovery Health Medical Scheme strives to pay your claims as quickly and as accurately as possible. If you have paid a claim up front, you need to provide proof of payment to be refunded. We will only accept the following as proof of payment: A receipt An internet bank transacton A Paid stamp on your claim Wording in your claim indicatng that you, the member or patent have paid Credit column on the claim with an amount showing This will ensure tmely and correct payment of your claim. What to remember when claiming Claims must be submited within four months from the end of the month in which the service was rendered. Older claims will be considered expired and will not be paid. Make sure that your membership number, the healthcare professionals details including the practce number are clear on the claim. Send a detailed claim and not just a receipt as we need the details of what you are claiming for to process your claim quickly and correctly. How to submit your claims Smartphone App Submit and keep track of your claims using the Discovery app on your iPhone or Android smartphone. Log into the app, select claims and then submit claims and follow the instructons. Download the app from the App Store or Google Play store. Upload On your laptop, smartphone or tablet, go to www.discovery.co.za. On the menu, hover over Health and click on Claims then select upload your claims. Upload now and follow the steps. Email Scan and email your claims to claims@discovery.co.za Post Post your claims to Discovery Claims, PO Box 784262, Sandton 2146 Fax Fax your claims to 0860 329 252 (please ensure that the fax details are clear by frst making a photocopy and then faxing that through). 35 35 Additonal informaton 36 UNIQUE SAVINGS ONLY WITH DISCOVERY HEALTH If you are registered on the Chronic Illness Benefit you get up to 25% cash back on a range of specialised products at Dis-Chem Pharmacies countrywide. You get cash back on a selection of monitoring devices, speciality food, health education, footwear and accessories as well as fitness and wellbeing items. Go to www.discovery.co.za/info/chronicare to register, view the catalogue of products and for more information. You get up to 25% cash back with MedSaver on over-the-counter (schedule 1 and 2) medicines at Clicks Pharmacies. Go to www.discovery.co.za or www.medsaver.co.za to actvate MedSaver now and start earning your cash back. Discovery Health has partnered with Clicks, Dis-Chem and Netcells to help you save up to 25% on healthcare-related spend. 37 You get an exclusive discount of 25% when you pay upfront for umbilical cord blood and tssue stem cell banking with Netcells Biosciences. When you choose to use a payment plan, you get a discount of 20%. Go to www.discovery.co.za for more informaton. 38 MEDXPRESS DOOR-TO-DOOR MEDICINE DELIVERY H o m e W o rk H o lid a y Have your monthly medicines delivered to your door. Delivering wherever you are 2014 Delivering the best of care MedXpress, Discovery Healths convenient medicine delivery service Now you can take standing in a long queue at the pharmacy of your already-overfowing to-do lists. MedXpress lets you order medicine online or over the phone and have it delivered directly to your door. MedXpress is also the convenient way to order repeatable medicine prescriptons. You have full cover for medicines on the Discovery Health medicine list (formulary). This means that you wont have to make any co-payments and you wont be charged above the Discovery Health Rate for medicines. 39 What Discovery MedXpress ofers you Convenience Delivery to your door Theres no need to wait in queues or leave home to get your medicine. A simple process there are no complicated forms to complete. All we need is a valid script and a phone call. Regular updates well keep you up to date on any changes that may afect your cover for chronic medicine when you call us to order your medicine. Advice to help you save When using MedXpress, Discovery Healths qualifed service agents can also advise you on the most cost-efectve alternatves. And you will always be charged at the Discovery Health Rate for medicines or less in efect getng rid of all those small co-payments that add up over tme. Important points to remember Delivery Chronic or repeatable prescripton medicine will be delivered to your preferred address anywhere in South Africa. Once-of prescripton medicine delivery orders are currently only available in Johannesburg, Pretoria and Cape Town metropolitan areas. How you can order medicine If youre placing your order for the frst tme, you need to clearly mark your prescripton with the words MedXpress and your Discovery Health Medical Scheme membership number. You can email your prescripton to medxpress@discovery.co.za or fax it to 011 539 1020 and you will receive an SMS from Discovery Health MedXpress. Once youve placed your frst order for chronic medicine you can use the Discovery smartphone app (downloadable in the App Store or Google Play), you can log in to www.discovery.co.za or call us to have your monthly repeat medicine orders delivered to an address of your choice. There is no additonal administraton or delivery cost, so you can take back the tme spent in the pharmacy by placing your order now. 40 40 THE DIGITAL WORLD OF DISCOVERY www.discovery.co.za and the Discovery app Our website has been designed to display optmally, whether you are accessing it from a desktop, laptop, tablet or smartphone. The Discovery app available on the App Store and Google Play puts your health plan in your pocket. Together they provide a wealth of self- service tools and informaton to help you manage your health plan and your health. Anytme, Anywhere. Translate your travel cover into one of fve languages Watch our educatonal videos Access your health records and grant your doctor consent to view them too Check medicine price and alternatves* View other Discovery products you have View informaton on hospital procedures Find a healthcare professional Track your benefts and medical spend Plan and authorise hospital admission* Order medicine for home delivery Access important documents Submit and track your claims *Only available on www.discovery.co.za 41 41 HEALTHID PUTTING YOUR MEDICAL INFORMATION IN YOUR DOCTORS HANDS HealthID puts your health records in your doctors hands. This is the frst electronic health record applicaton of its kind in South Africa. With Discovery Healths HealthID tablet app doctors can: To beneft from HealthID, your doctor will need your permission to access your health records. You will need to give consent to each doctor you visit before that doctor can access your health records on HealthID. You can log onto www.discovery.co.za to give your consent. No unauthorised person will have access to your personal medical informaton. Apply for chronic cover If you are diagnosed with a chronic conditon, your doctor can complete an electronic Chronic Illness Beneft applicaton using the HealthID app. This applicaton is easy and convenient, because your doctor gets the informaton they need for your specifc conditon when completng the applicaton and you can get immediate approval for certain conditons. Access medical histories and electronic health records A doctor can go into your electronic health records and access your health informaton to see your medical history. So, if you are having trouble remembering partcular medicines youve taken, this informaton is available to your doctor immediately. You can save tme and money by not having to repeat tests and investgatons, because the results of your previous tests are available for your doctor to see. View beneft informaton Your doctor also has instant access to your health beneft informaton to help you get the most out of your benefts. All these functons are designed to make doctors visits easier and more productve. Write electronic scripts Your doctor can prescribe medicine during a consultaton with you using electronic scriptng. Your doctor can also see medicines on the approved medicine list, as well as the cost of those medicines. You can fnd ways to reduce or even avoid co-payments on your medicines before you even reach the pharmacy. 42 NOTES GM_23378DHM_19/12/13_V10 KCFFE 10/13(14) Discovery Health Medical Scheme|16 Fredman Drive|Sandton|0860 99 88 77|www.discovery.co.za Discovery Health (Pty) Ltd registration 1997/013480/07, administers Discovery Health Medical Scheme, Registration number 1125. Discovery Health (Pty) Ltd is an authorised financial services provider.