Discovery Coastal Core & Specialists

Scooby_Doo

Scooby_Doo

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Hi all,

I know the Coastal Core is a hospital plan, but if I was to be refereed to a Specialist by a GP would Discovery cover the Specialist?

Or would I need to be hospitalised first and then after would Discover cover Specialists?
 
We are on coastal core, and even if you are hospitalized they only cover 100% of the hospital bill and the doctors. Most specialists does charge 300% and more, so either you need Gap cover to cover that, or pay it out of pocket. Remember with hospital plan, they only pay for authorized hospital visits, nothing out of hospital!
 
I have gap cover which is fine, was just wondering what would happen if I went to a GP and he found something interesting and sent me off to a specialist.

Would Discovery pay for said specialist visit or would that count as out of hospital?
 
Scooby_Doo said:
I have gap cover which is fine, was just wondering what would happen if I went to a GP and he found something interesting and sent me off to a specialist.

Would Discovery pay for said specialist visit or would that count as out of hospital?
Click to expand...

They wont pay. It will come out of your MSA if you have some. They only cover specialist if you are in hospital.
 
Scooby_Doo said:
I have gap cover which is fine, was just wondering what would happen if I went to a GP and he found something interesting and sent me off to a specialist.

Would Discovery pay for said specialist visit or would that count as out of hospital?
Click to expand...
They only pay for hospitalization... If you are checked into hospital by the specialist and the specialist bill is part of the hospital bill it is covered, I think. Outside of hospital you are not covered.
 
Cool, thanks.

Final question, lets say I get sent to a dermatologist and said dermatologist sends me for a procedure to remove some moles for testing at a hospital. Would this count as "in hospital"?

I will follow up with Discovery and such but I would like a feeling of what the definition on "in hospital" means before I start calling.
 
Scooby_Doo said:
Cool, thanks.

Final question, lets say I get sent to a dermatologist and said dermatologist sends me for a procedure to remove some moles for testing at a hospital. Would this count as "in hospital"?

I will follow up with Discovery and such but I would like a feeling of what the definition on "in hospital" means before I start calling.
Click to expand...
Think they would just take a sample at the dermatologist. I think in hospital is being admitted to an hospital and staying over night. Except for medical emergencies.

Either way I think you will be footing the bill.
 
Scooby_Doo said:
Cool, thanks.

Final question, lets say I get sent to a dermatologist and said dermatologist sends me for a procedure to remove some moles for testing at a hospital. Would this count as "in hospital"?

I will follow up with Discovery and such but I would like a feeling of what the definition on "in hospital" means before I start calling.
Click to expand...
I think that if the procedure is done in hospital it counts, but I'm not actually sure. Just call them and report back to us :)
 
_Hecate_ said:
Think they would just take a sample at the dermatologist. I think in hospital is being admitted to an hospital and staying over night. Except for medical emergencies.

Either way I think you will be footing the bill.
Click to expand...

I know someone who had an ENT specialist specifically do a procedure in a hospital, rather than in his practice rooms as he normally would, specifically because the medical aid covered it when done in hospital but not in his rooms. I don't know what medical aid it was or if it's relevant here, but it does happen that a procedure that can be done both in and out of a hospital will be covered in the former case and not in the latter case.
 
i work for Discovery Health clinical department, feel free to inbox me
 
Scooby_Doo said:
Hi all,

I know the Coastal Core is a hospital plan, but if I was to be refereed to a Specialist by a GP would Discovery cover the Specialist?

Or would I need to be hospitalised first and then after would Discover cover Specialists?
Click to expand...

I'm sure Coastal Core has an MSA plan as well,not only Hospital plan.I was on a MSA plan with Coastal Core and then moved to a Hospital Plan..stand to be corrected.

On Coastal Core: you must go to a hospital in one of the four coastal provinces to be covered in full. If you don’t use a coastal hospital, we pay up to a maximum of 70% of the hospital account and you have to pay the difference. This does not apply in an emergency.
Your hospital cover is for:

The account from the hospital
All other accounts – like accounts from your admitting doctor, anaesthetist or any approved healthcare professionals while in hospital. We call these related hospital accounts.
 
Your cover for healthcare
professionalsFull cover for specialists who we have an
agreement with
You can benefit by using healthcare professionals
who we have an agreement with as we will
cover their approved procedures in full.
These healthcare professionals, appropriate to
your plan, are also the designated providers for
Prescribed Minimum Benefits.
You can access the MaPS Advisor on www.discovery.co.za
to search for healthcare professionals who we have an
agreement with.
You may have a co-payment if you use other specialists
If you are treated by a specialist who we do not have
an agreement with, we cover you up to 100% of the
Discovery Health Rate.
Other healthcare professionals
We cover GPs and other healthcare services up to 100% of
the Discovery Health Rate.
We cover radiology and pathology up to 100% of the
Discovery Health Rate.

The above is a copy of the Coastal Core Plan guide for 2012. I hope it helps
 
Defib said:
i work for Discovery Health clinical department, feel free to inbox me
Click to expand...

Why not just answer here so that we can all see the answer? Inbox me always sounds like an attempt to sell something.

Even as someone who sells the product, health plans are always a tough one to give specifics on. You get given a procedure code for anything done and then the medical aid checks to see whether this procedure code is covered by your specific plan. On certain plans, but I cannot say for sure here, some procedures are covered in the doctor's/specialist's rooms. The reason for this is due to the "cheating of the system" described above where a procedure is specifically done in hospital, even when it can be done out, just to get the medical aid to cover it. The medical aid would be far better off just covering it out of hospital.

As stated by others, the only way you know for certain is to phone Discovery with the procedure code, which you can get from the doctor or specialist, and ask if it will be covered.
 
ok fair enough

The CORE series is an in hospital only plan and has NO medical savings account or MSA. All day to day expenses will be covered from the member's own pocket.

Designated Service Providers : These are the providers ( Dr's, Specialists, surgeons etc) who have an agreement with Discovery Health. Now if you use there services, your treatment in hospital will be covered in full. Some providers dont have an agreement with DH thus they charge more.

If you are on Coastal Core - you consults out of hospital will be for your own pocket however, for an approved authorised hospital admission, you will be covered at 100% of the DH rate - and The Classic Core 200%. So moral of the story, find a DSP for your plan type. That info is on the DH site.

Certain procedures that come out of the hospital benefit (risk portion, i,e DH pays) that can be performed in Dr's rooms such as a gastroscopy.

Have i left anything out???
 
I had a situation last year, where I had kidney problems. Urologist had to have a scan(10k) done, and some tests as well. So he had me hospitalized, so that the hospital plan would cover. We did not pay a cent in. If it is a procedure that needs doing that is expensive, chat to your doc and see what your options are.
 
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