Above Threshold Benefit (ATB)

The Above Threshold Benefit (ATB) gives you extra cover when your claims add up to a set amount called the Annual Threshold, if you are on an Executive, Comprehensive or Priority plan.

Once all the claims you have sent to us add up to the Annual Threshold, we pay the rest of your claims from the Above Threshold Benefit (ATB), at the OneHealth Rate (OHR) or a portion of it. The Executive and Comprehensive plans have an unlimited Above Threshold Benefit (ATB), and the Priority plans have a limited ATB.

Read more about the ATB.

Additional Disease List (ADL)

Once approved on the Chronic Illness Benefit (CIB), you have cover for medicine for additional diseases that we cover over and above the 27 chronic conditions if you're on our Executive or Comprehensive plans. The conditions are:

Ankylosing spondylitis, Behcets' disease, cystic fibrosis, delusional disorder, Dermatopolymyositis, generalised anxiety disorder, Huntington's disease, major depression, muscular dystrophy and other inherited myopathies, myasthenia gravis, obsessive compulsive disorder, osteoporosis, isolated growth hormone deficiency, motor neuron disease, Paget's disease, panic disorder, polyarteritis nodosa, post-traumatic stress disorder, psoriatic arthritis, pulmonary intestinal fibrosis, Sjögren's syndrome, systemic sclerosis, Wegener's granulomatosis.

Annual Threshold

We add up the OneHealth Rate of the day-to-day claims you send us. When your day-to-day claims reach a fixed rand amount - what we call the Annual Threshold - we pay claims from the Above Threshold Benefit, if you are on an Executive, Comprehensive or Priority plan. We set the Annual Threshold amount at the beginning of each year.

You can view the Annual Threshold amounts here.

Chronic Disease List (CDL)

The Chronic Disease List (CDL) is a defined list of chronic conditions we cover according to the Prescribed Minimum Benefits (PMBs). The conditions are:

Addison's disease, asthma, bipolar mood disorder, bronchiectasis, cardiac failure, cardiomyopathy, chronic obstructive pulmonary disease, chronic renal disease, coronary artery disease, Crohn's disease, diabetes insipidus, diabetes Type 1, diabetes Type 2, dysrhythmia, epilepsy, glaucoma, haemophilia, HIV, hyperlipidaemia, hypertension, hypothyroidism, multiple sclerosis, Parkinson's disease, rheumatoid arthritis, schizophrenia, systemic lupus erythematosus, ulcerative colitis

Chronic Illness Benefit (CIB)

The Chronic Illness Benefit (CIB) covers you for a defined list of chronic conditions. You need to apply to have your medicine covered for your chronic condition.

All our plans cover approved medicine for the Prescribed Minimum Benefit Chronic Disease List conditions. Certain plans cover additional conditions.

Prescribed Minimum Benefit (PMB) conditions

You have access to treatment for a list of medical conditions under the Prescribed Minimum Benefits (PMBs). The PMBs cover the 27 chronic conditions on the Chronic Disease List (CDL). All our plans offer benefits that are far richer than the PMBs. To access PMBs, certain rules apply (see Prescribed Minimum Benefits).

Medicine cover for the Chronic Disease List

You get full cover for approved chronic medicine on our medicine list. For medicine not on our list, we cover you up to a set monthly rand amount called the Chronic Drug Amount (CDA). The CDA does not apply to the Smart and KeyCare plans. On these plans you will have to pay for medicine that is not on the medicine list.

Medicine cover for the Additional Disease List

The Executive and Comprehensive plans offer cover for medicine on the Additional Disease List (ADL). You are covered up to the set monthly CDA for your medicine. No medicine list applies.

Extended chronic medicine list

Members on the Executive Plan also have full cover for an exclusive list of brand medicines.

How we pay for medicine

We pay for medicine up to a maximum of the OneHealth Rate for medicine. The OneHealth Rate for medicine is the price of the medicine as well.

What is the Chronic Disease List and its conditions?

The Chronic Disease List (CDL) is a defined list of chronic conditions we cover according to the Prescribed Minimum Benefits (PMBs). The conditions are:

Addison's disease, asthma, bipolar mood disorder, bronchiectasis, cardiac failure, cardiomyopathy, chronic obstructive pulmonary disease, chronic renal disease, coronary artery disease, Crohn's disease, diabetes insipidus, diabetes Type 1, diabetes Type 2, dysrhythmia, epilepsy, glaucoma, haemophilia, HIV, hyperlipidaemia, hypertension, hypothyroidism, multiple sclerosis, Parkinson's disease, rheumatoid arthritis, schizophrenia, systemic lupus erythematosus, ulcerative colitis

What is the Additional Disease List and its conditions?

These are additional diseases that we cover over and above the 27 chronic conditions if you're on our Executive or Comprehensive plans. The conditions are:

Ankylosing spondylitis, Behcets' disease, cystic fibrosis, delusional disorder, Dermatopolymyositis, generalised anxiety disorder, Huntington's disease, major depression, muscular dystrophy and other inherited myopathies, myasthenia gravis, obsessive compulsive disorder, osteoporosis, isolated growth hormone deficiency, motor neuron disease, Paget's disease, panic disorder, polyarteritis nodosa, post-traumatic stress disorder, psoriatic arthritis, pulmonary intestinal fibrosis, Sjögren's syndrome, systemic sclerosis, Wegener's granulomatosis.

Contribution

This is the monthly amount you pay for your cover for medical costs.

Day-to-day Extender Benefit (DEB)

On the Executive, Comprehensive, Priority and Saver Plans we extend your day-to-day cover through the Day-today Extender Benefit (DEB) when you have spent your annual Medical Savings Account allocation and before you reach your Annual Threshold, where applicable for GP consultation fees and kids casualty visits. Cover depends on the plan you choose.

Delta Hospital Network

If you are on a Delta plan, this is a network of specific hospitals you must use for planned procedures to be covered.

View the Delta Hospital Network.

Designated Service Provider (DSP)

A designated service provider is a healthcare provider (such as a doctor, specialist, allied healthcare professional, pharmacist or hospital) that is a medical scheme's first choice when members need diagnosis, treatment or care for a Prescribed Minimum Benefit condition.

If you choose not to use a designated service provider, you may have to pay a portion of the bill yourself. This could either be a percentage co-payment or the difference between the OneHealth Rate and that charged by the healthcare provider you used.

OneHealth Rate (OHR)

This is a rate set by us at which healthcare services from hospitals, pharmacies and healthcare professionals are paid.

Healthcare professional

Healthcare professionals are individuals who provide preventive, curative, promotional or rehabilitative healthcare services to people, families or communities. These include general practitioners (GPs), specialists, nurses, physiotherapists, psychologists, dentists, pathologists and radiologists.

KeyCare Hospital Network

If you are on a KeyCare plan, this is a network of specific providers, both in hospital and out of hospital, which you must use in order to be covered.

View the KeyCare Hospital Network.

Limits

Most in-hospital and out-of-hospital healthcare benefits do not have an upper limit, but some healthcare services, such as dentistry and optometry, have yearly limits that apply. It's important to familiarise yourself with these limits and to keep track of your use of them. OneHealth Medical Scheme members can do this by logging in to the Discovery website.

Medical Savings Account (MSA)

On the Executive, Comprehensive, Priority and Saver plans, the Medical Savings Account (MSA) is an amount that is allocated to you at the beginning of each year or when you join the Scheme. You pay this amount back in equal portions as part of your monthly contribution. We pay your day-to-day medical expenses such as GP and specialist consultations, acute medicine, radiology and pathology from the available funds allocated to your MSA. Any unused funds will carry over to the next year. Should you leave the Scheme or change your plan partway through the year and have used more of the funds than what you have contributed, you will need to pay the difference to us. Learn more about the Medical Savings Account.

Medicine list or formulary

This is a list of approved medicine we pay for in full. This list includes an extensive range of high-quality medicine to make sure you always have the option of full cover.

View any one of our medicine lists (formularies) here.

What if I suffer side effects from medicine on the formulary?

If this happens, or if substituting your current medicine with medicine on the formulary has a negative effect on your health, you and your doctor can put your case to us and ask us to pay for your medicine.

The forms to appeal are available here.

Networks

Some plans, benefits and healthcare services require you to use the Scheme's network providers. Use our extensive networks of healthcare providers to get full cover.

1. Hospitals
   If you have chosen a plan with a hospital network, make sure you use a hospital in that network to get full cover. The Delta, Coastal, Smart and KeyCare plans offer hospital cover in a defined network of hospitals. On the Coastal Plan, you must go to a selected hospital in one of the four coastal provinces for a planned admission.

   View the Hospital Network List.

2. GPs and specialists
   You have full cover for GPs and specialists who we have payment arrangements with.
3. Day-to-day Extender Benefit
   Use a network provider to access the Day-to-day Extender Benefit and get full cover depending on your plan for GP consultation fees and kids' casualty visits.

Payment arrangement

The Scheme has entered into payment arrangements with various healthcare professionals that have agreed to charge at the OneHealth Rate. You benefit from access to the broadest range of doctors, which represents over 90% of our members' doctor interactions. If you use healthcare professionals that we don't have payment arrangements with, we will pay at the rate applicable to your chosen plan and you may have a co-payment.

Prescribed Minimum Benefits (PMBs)

In terms of the Medical Schemes Act of 1998 (Act No. 131 of 1998) and its Regulations, all medical schemes have to cover the costs related to the diagnosis, treatment and care of:

• An emergency medical condition
• A defined list of 270 diagnoses
• A defined list of 26 chronic conditions

To access Prescribed Minimum Benefits (PMBs), there are rules that apply:

• Your medical condition must qualify for cover and be part of the defined list of Prescribed Minimum Benefit (PMB) conditions.
• The treatment needed must match the treatments in the defined benefits.
• You must use designated service providers (DSPs) in our network. This does not apply in emergencies. However even in these cases, where appropriate and according to the rules of the Scheme, you may be transferred to a hospital or other service providers in our network, once your condition has stabilised.

If your treatment doesn't meet the above criteria, we will pay up to 80% of the OneHealth Rate. You will be responsible for the difference between what we pay and the actual cost of your treatment.

What is an emergency
An emergency medical condition, also referred to as an emergency, is the sudden and, at the time 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.

For more information, read our Guide to Prescribed Minimum Benefits, Prescribed Minimum Benefit treatment guidelines, Guide to Prescribed Minimum Benefits for in-hospital treatment and Prescribed Minimum Benefit list of conditions.

Self-payment Gap (SPG)

The Self-payment Gap (SPG) is applicable to plans that have a Medical Savings Account, and refers to a temporary gap in cover when you run out of funds in your Medical Savings Account but have not yet reached your Annual Threshold.

You must still send claims to us so that we know when to start paying from your Above Threshold Benefit (ATB).

Read more about the SPG.

Smart Hospital Network

If you are on the Smart Plan, this is a network of specific providers, both in hospital and out of hospital, which you must use to be covered.

View the Smart Plan Hospital Network.

Voice biometrics

Using the unique characteristics of your voice, voice biometrics helps secure your identity when you call our call centre. This technology will save you time and improve the convenience of service you receive.

Click here for more information and to register.