GUIDE TO PRESCRIBED

MINIMUM BENEFITS FOR

IN-HOSPITAL TREATMENT
DISCOVERY HEALTH MEDICAL SCHEME
2024

Discovery Health Medical Scheme, registration number 1125, is regulated by the Council for Medical Schemes and administered by Discovery Health (Pty) Ltd, registration
number 1997/013480/07, an authorised financial services provider.
Overview
In terms of the Medical Schemes Act No. 131 of 1998, Prescribed Minimum Benefits (PMBs) are a set of defined benefits that all
registered medical schemes in South Africa are obliged to provide for all their members. All members have access to these
benefits, irrespective of their chosen plan type. Prescribed Minimum Benefits (PMBs) ensure that all medical scheme members
have access to continuous care to improve their health.

Discovery Health Medical Scheme plans are structured in such a way that the member’s chosen health plan provides
comprehensive cover. Some plans cost more but offer more comprehensive cover, while others have lower contributions with
fewer benefits. Irrespective of this, all our plans cover more than just the minimum benefits required by law. Always consult your
Health Plan Guide to see how you are covered.

This document tells you how the Scheme covers the Prescribed Minimum Benefits (PMBs) for in-hospital treatment. Please refer
to the Prescribed Minimum Benefit (PMB) guide on www.discovery.co.za under Medical Aid > Find documents and certificates for
more details about Prescribed Minimum Benefits (PMBs) and how they are covered.

About some of the terms we use in this document

There may be some terms we refer to in the document that you may not be familiar with. Here are the meanings of these terms.

TERMINOLOGY DESCRIPTION

Comprehensive cover This cover includes benefits that go beyond the essential healthcare services and Prescribed
Minimum Benefits as prescribed by the Medical Schemes Act. Comprehensive cover offers
additional cover and supplementary benefits to compliment basic cover. You have the flexibility to
choose your healthcare options and service providers. Whether it's full cover or options outside of
full cover, we give you the freedom to decide what suits your needs. Our cover is in line with or
goes beyond defined clinical best practices. This makes sure that you get treatment that is
expected and clinically appropriate.

We may review these principles from time to time to stay current with changes in the healthcare
landscape. While comprehensive, cover remains subject to the Scheme’s treatment guidelines,
protocols, and designated service providers. We still prioritise managed care to ensure the best
outcomes for your health.

Co-payment This is an amount that you need to pay towards a healthcare service. The amount can vary by the
type of covered healthcare service, place of service or if the amount the service provider charges is
higher than the rate we cover. If the co-payment amount is higher than the amount charged for the
healthcare service, you will have to pay for the cost of the healthcare service.

Day-to-day benefits These are the available funds allocated to the Medical Savings Account (MSA) and Above Threshold
Benefit (ATB), where applicable. Depending on the plan you choose, you may have cover for a
defined set of day-to-day benefits. The level of day-to-day benefits depends on the plan you
choose.

Designated service provider A healthcare provider (for example doctor, specialist, allied healthcare professional, pharmacy or
(DSP) hospital) who we have an agreement with to provide treatment or services at a contracted rate.
Visit www.discovery.co.za or click on Find a healthcare provider on the Discovery Health app to
view the full list of designated service providers (DSPs).

Discovery Health Rate This is a rate we pay for healthcare services from hospitals, pharmacies, healthcare professionals
(DHR) and other providers of relevant health service.

Discovery Health Rate for This is the rate at which Discovery Health Medical Scheme will pay for medicine. It is the Single Exit
Medicine Price of medicine plus the relevant dispensing fee.

GUIDE TO PRESCRIBED MINIMUM BENEFITS FOR IN-HOSPITAL TREATMENT 2

Discovery Health Medical Scheme, registration number 1125, is regulated by the Council for Medical Schemes and administered by Discovery Health (Pty) Ltd,
registration number 1997/013480/07, an authorised financial services provider. Find a healthcare provider and the Discovery Health app are brought to you by Discovery
Health (Pty) Ltd; registration number 1997/013480/07, an authorised financial services provider and administrator of medical schemes.
 TERMINOLOGY DESCRIPTION

ICD-10 code A clinical code that describes diseases and signs and symptoms, abnormal findings, complaints,
social circumstances and external causes of injury or diseases, as classified by the World Health
Organization (WHO).

Member The reference to member in this document also includes dependents, where applicable.

Emergency medical An emergency medical condition, also referred to as an emergency, is the sudden and, at the time,
condition unexpected onset of a health condition that requires immediate medical and surgical treatment,
where failure to provide medical or surgical treatment would result in serious impairment to bodily
functions or serious dysfunction of a bodily organ or part or would place the person’s life in serious
jeopardy.

An emergency does not necessarily require a hospital admission. We may ask you for additional
information to confirm the emergency.

Related accounts Any account other than the hospital account for in-hospital care. This could include the accounts
for the admitting doctor, anaesthetist and any approved healthcare expenses like radiology or
pathology.

What is a Prescribed Minimum Benefit (PMB)?

Prescribed Minimum Benefits (PMBs) are guided by a list of medical conditions as defined in the
Medical Schemes Act 131 of 1998
According to the Medical Schemes Act 131 of 1998 and its Regulations, all medical schemes have to cover the costs related to the
diagnosis, treatment and care of:
1. Any life-threatening emergency medical condition
2. A defined set of 271 diagnostic treatment pairs
3. 27 chronic conditions (Chronic Disease List conditions).

Please refer to the Council for Medical Schemes website www.medicalschemes.co.za for a full list of the 271 diagnostic treatment
pairs. All medical schemes in South Africa have to include the Prescribed Minimum Benefits (PMBs) in the plans they offer to their
members.

Requirements you must meet to benefit from Prescribed Minimum Benefits (PMBs)
There are certain requirements before you can benefit from Prescribed Minimum Benefits (PMBs). The requirements are:
1. The condition must qualify for cover and be on the list of defined Prescribed Minimum Benefit (PMB) conditions.
2. The treatment needed must match the treatments in the defined benefits on the Prescribed Minimum Benefit (PMB)
list.
3. You must use the Scheme's designated service providers (DSPs) for full cover unless there is no designated service
provider (DSP) applicable to your chosen health plan.

If you do not use a designated service provider (DSP) we will pay up to 80% of the Discovery Health Rate (DHR). You will be
responsible for the difference between what we pay and the actual cost of your treatment. This does not apply in emergencies.
However, even in these cases, where appropriate and according to Scheme Rules, you may be transferred to a hospital or other
service providers in our network once your condition has stabilised, to avoid co-payments. If your treatment doesn’t meet the
above criteria, we will pay according to your health plan benefits.

Important to note
• Prescribed Minimum Benefit (PMB) regulations and their accompanying provisions do not apply to healthcare services
obtained outside the borders of South Africa.

GUIDE TO PRESCRIBED MINIMUM BENEFITS FOR IN-HOSPITAL TREATMENT 3

Discovery Health Medical Scheme, registration number 1125, is regulated by the Council for Medical Schemes and administered by Discovery Health (Pty) Ltd,
registration number 1997/013480/07, an authorised financial services provider. Find a healthcare provider and the Discovery Health app are brought to you by Discovery
Health (Pty) Ltd; registration number 1997/013480/07, an authorised financial services provider and administrator of medical schemes.
 • Prescribed Minimum Benefit (PMB) related claims for services obtained outside the borders of South Africa shall be
treated as in accordance with your chosen health plan benefits, subject to the relevant Scheme Rate and any other
limitations applicable to your benefits within the borders of South Africa.

There are a few instances where you will only have Prescribed Minimum Benefit (PMB) cover
This happens when you have a waiting period or when you have treatments linked to conditions that are excluded by your health
plan. This can be a three-month general waiting period or a 12-month condition-specific waiting period. Depending on the
category of waiting periods, you may still qualify for cover from the Prescribed Minimum Benefits.

There are some circumstances where you do not have cover for Prescribed Minimum Benefit
(PMBs)
This can happen when you join a medical scheme for the first time, with no medical scheme membership before that. Also, if you
join a medical scheme more than 90 days after leaving your previous medical scheme. In both these cases, the Scheme could
impose waiting periods, during which you and your dependants will not have access to the Prescribed Minimum Benefit (PMBs),
regardless of the conditions you may have. We will communicate with you at the time of applying for membership, if waiting
periods apply.

How we pay for In-Hospital Prescribed Minimum Benefits (PMBs)

We pay for confirmed Prescribed Minimum Benefits (PMBs) in full if you receive treatment from a designated service provider
(DSP) and/or preferred supplier. Treatment received from a non-designated service provider (non-DSP) or medical items from a
supplier who is not a preferred supplier may be subject to a co-payment if the healthcare provider or supplier charges more than
the amount we pay.

There are some instances when you will still have full cover if you use a healthcare provider who we do not have a payment
arrangement with:
• The in-hospital event was an emergency.
• The use of a non-DSP was involuntary.
• There is no DSP available at the time of the event.

We may require additional supporting documents to confirm cover as a Prescribed Minimum Benefit (PMB). Documents may be
requested confirming your Prescribed Minimum Benefit (PMB) diagnosis, for example Magnetic Resonance Imaging (MRI) scans
and endoscopic procedure reports.

In cases where there are no services or beds available at a designated service provider (DSP) when you or one of your
dependants needs treatment, you must contact us on 0860 99 88 77. We will intervene and make arrangements for an
appropriate facility or healthcare provider to accommodate you.

We pay for benefits not included in the Prescribed Minimum Benefits (PMBs) from your appropriate and available Hospital
Benefit and/or day-to-day benefits, according to the rules of your chosen health plan.

Using the designated healthcare service providers

You must use healthcare providers who we have a payment arrangement with so that you do not experience co-payments. In an
emergency, you can go directly to hospital and notify the Scheme of your admission as soon as possible. In the case of an
emergency, you are covered in full for the first 24 hours or until you are stable enough to be transferred.

You can use Find a healthcare provider on www.discovery.co.za or the Discovery Health app to find designated service providers
(DSPs) who we have a payment arrangement with, for your specific health plan. Some examples of designated service providers
(DSPs) when admitted to hospital, include hospitals, specialists, GPs, psychologists and social workers.

Get preauthorisation for hospitalisation and other procedures

What preauthorisation is and what it means

GUIDE TO PRESCRIBED MINIMUM BENEFITS FOR IN-HOSPITAL TREATMENT 4

Discovery Health Medical Scheme, registration number 1125, is regulated by the Council for Medical Schemes and administered by Discovery Health (Pty) Ltd,
registration number 1997/013480/07, an authorised financial services provider. Find a healthcare provider and the Discovery Health app are brought to you by Discovery
Health (Pty) Ltd; registration number 1997/013480/07, an authorised financial services provider and administrator of medical schemes.
Preauthorisation is the approval of certain procedures and any planned admission to a hospital before the procedure or planned
admission takes place. It includes associated treatment or procedures performed during hospitalisation. Whenever your doctor
plans a hospital or day-clinic admission for you, you must let us know at least 48 hours before you go to the hospital or day-clinic.

You also need specific preauthorisation for Magnetic Resonance Imaging (MRI) and Computed Tomography (CT) scans, radio-
isotope studies, and for certain endoscopic procedures, whether done in hospital or not.

In an emergency you must go directly to a hospital and notify the Scheme as soon as possible of your admission. In the case of an
emergency, you are covered in full for the first 24 hours or until you are stable enough to be transferred.

Contact us for preauthorisation

Call us on 0860 99 88 77 to get preauthorisation. We will give you an authorisation number. Please give the authorisation number
to the relevant healthcare provider and ask them to include this when they submit their claims. Please make sure you
understand what is included in the authorisation and how we will pay your claims.

We will ask for the following information when you request preauthorisation
• Your membership number
• Details of the patient (name and surname, ID number, and other relevant information)
• Date and time of the admission
• Practice number for the hospital or day clinic, and admitting doctor
• Reason for the procedure or hospitalisation
• Diagnostic codes (ICD-10 codes), tariff codes and procedure codes (you must get these from your treating doctor).

Please note: If you don’t preauthorise your admission, we will only pay 70% of the costs we would normally cover on the hospital
and related accounts.

Preauthorisation does not guarantee payment of all claims

Your hospital cover

Your hospital cover includes:
• Cover for the account from the hospital which includes the ward and theatre fees
• Cover for the accounts from your treating healthcare professionals such as the admitting doctor, anaesthetist and any
approved healthcare expenses like radiology or pathology, which are separate from the hospital account and are called
related accounts.

There are some expenses you may have in hospital as part of a planned admission that your Hospital Benefit does not cover, for
example certain procedures, medicine and new technologies, which may need separate approval. It is important that you discuss
this with your healthcare professional. Please take note that benefit limits, Scheme rules, treatment guidelines and managed care
criteria may apply to some healthcare services and procedures in hospital. Find out more about these by contacting us on 0860
99 88 77 or visit www.discovery.co.za under Medical Aid > Benefits and cover > Do we cover for more information on how you will
be covered.

Getting the most out of your cover

Elective admissions for Prescribed Minimum Benefit (PMB) conditions and procedures are covered in full if you choose to use a
designated service provider (DSP) hospital and designated service provider (DSP) treating doctors. Where your primary treating
doctor is a designated service provider (DSP), reimbursement will be made in full without any co-payment to yourself for any
required anaesthetic services you may need during your admission.

The below conditions need to be met for full cover for these providers:
• You are being admitted for a procedure for a Prescribed Minimum Benefit (PMB) condition
• Your chosen hospital or day facility is on the Prescribed Minimum Benefit (PMB) network for your plan
• Your primary treating doctor is on the Prescribed Minimum Benefit (PMB) network for your plan.

If all of the above conditions are met your hospital, doctor and anaesthetist accounts will be covered in full.

GUIDE TO PRESCRIBED MINIMUM BENEFITS FOR IN-HOSPITAL TREATMENT 5

Discovery Health Medical Scheme, registration number 1125, is regulated by the Council for Medical Schemes and administered by Discovery Health (Pty) Ltd,
registration number 1997/013480/07, an authorised financial services provider. Find a healthcare provider and the Discovery Health app are brought to you by Discovery
Health (Pty) Ltd; registration number 1997/013480/07, an authorised financial services provider and administrator of medical schemes.
For the most updated information, visit www.discovery.co.za or click on Find a healthcare provider using your Discovery Health
app or call us on 0860 99 88 77 to find a participating designated service provider (DSP).

Working to care for and protect you

Our goal is to provide support for you in the times when you need it most.

How to contact us
Tel (members): 0860 99 88 77, Tel (health partners): 0860 44 55 66
Go to www.discovery.co.za to Get Help or ask a question on WhatsApp. Save this number 0860 756 756 on your phone and say
"Hi" to start chatting with us 24/7.
PO Box 784262, Sandton, 2146. 1 Discovery Place, Sandton, 2196.

What to do if you have a complaint

01 | TO TAKE YOUR QUERY FURTHER:

If you have already contacted the Discovery Health Medical Scheme and feel that your query has still not been resolved, please
complete our online complaints form on www.discovery.co.za. We would also love to hear from you if we have exceeded your
expectations.

02 | TO CONTACT THE PRINCIPAL OFFICER:

If you are still not satisfied with the resolution of your complaint after following the process in Step 1 you are able to escalate
your complaint to the Principal Officer of the Discovery Health Medical Scheme. You may lodge a query or complaint with
Discovery Health Medical Scheme by completing the online form on www.discovery.co.za or by emailing
[email protected].

03 | TO LODGE A DISPUTE:
If you have received a final decision from Discovery Health Medical Scheme and want to challenge it, you may lodge a formal
dispute. You can find more information of the Scheme’s dispute process on the website.

04 | TO CONTACT THE COUNCIL FOR MEDICAL SCHEMES:

Discovery Health Medical Scheme is regulated by the Council for Medical Schemes. You may contact the Council at any stage of
the complaints process, but we encourage you to first follow the steps above to resolve your complaint before contacting the
Council. Contact details for the Council for Medical Schemes: Council for Medical Schemes Complaints Unit, Block A, Eco Glades
2 Office Park, 420 Witch-Hazel Avenue, Eco Park, Centurion 0157 | [email protected] | 0861 123 267 |
www.medicalschemes.co.za.

Your privacy is important to us

We hold your privacy in the highest regard. Our unwavering commitment to protecting your personal information and ensuring
the security and confidentiality of your data is clearly outlined in our Privacy Statement. You can view our latest version on
www.discovery.co.za > Medical aid > About Discovery Health Medical Scheme.

GUIDE TO PRESCRIBED MINIMUM BENEFITS FOR IN-HOSPITAL TREATMENT 6

Discovery Health Medical Scheme, registration number 1125, is regulated by the Council for Medical Schemes and administered by Discovery Health (Pty) Ltd,
registration number 1997/013480/07, an authorised financial services provider. Find a healthcare provider and the Discovery Health app are brought to you by Discovery
Health (Pty) Ltd; registration number 1997/013480/07, an authorised financial services provider and administrator of medical schemes.