keyhealth marketing brochure 2012 final
TRANSCRIPT
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BENEFITS BROCHURE 2012
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welcome to
KEYHEALTH
KeyHealth (referred to as the Scheme) is an open medical scheme that provides quality medical cover
to more than 88 000 lives throughout South Africa.
Since inception, the Scheme has earned the reputation of looking after its Members with innovative and
affordable products, backed by efficient administration and service.
KeyHealth offers 5 benefit options. These options are designed to cater for different needs in level of cover
and affordability.
Select an option based on your individual needs and financial position. KeyHealth has an extensive, but
select broker network. Our brokers are accredited and adhere to relevant legislation. Consult with anaccredited KeyHealth broker should you need assistance in choosing an option. Alternatively, call our
Centurion sales office on 012 667 5100.
ESSENCE OPTIONThis is an entry level option providing hospital cover only.
Hospitalisation is unlimited and covered at 100% of theagreed tariff.
EQUILIBRIUM OPTION
Hospitalisation is unlimited and covered at 100% of theagreed tariff. In-hospital, specialist services are covered up to
150% of MST. Out-of-hospital expenses are recoverable froma medical savings account and day-to-day benefits.
SILVER OPTION This option provides unlimited hospital cover at 100% of theagreed tariff with adequate day-to-day benefits. It is suitablefor younger families.
GOLD OPTIONThis option provides unlimited hospital cover at 100% of theagreed tariff with a medical savings account and a generousday-to-day benefit.
PLATINUM OPTIONThis option provides the most comprehensive cover.
Hospitalisation is unlimited and covered at 100% of theagreed tariff.
HEALTH BOOSTER (Included in all options) - This programme is aimed at preventativetreatment. It is important to note that this benefit is provided in addition to the benefits offered by
your specific option. Please turn to page 4 to see how Health Booster can enhance your cover at no
additional cost!
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KE
YHEALT
H
optio
ns
HOSPITALISATION
CHRONIC
HEALTH BOOSTER
HOSPITALISATION
SAVINGS
DAY-TO-DAY
CHRONIC
HEALTH BOOSTER
HOSPITALISATION
DAY-TO-DAY
CHRONIC
HEALTH BOOSTER
HOSPITALISATION
SAVINGS
DAY-TO-DAY
CHRONIC
HEALTH BOOSTER
HOSPITALISATION
DAY-TO-DAY
CHRONIC
HEALTH BOOSTER
essence
equilibrium
silver
gold
platinum
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04 KEYHEALTH MARKETING BROCHURE 2012
HEALTH BOOSTER PROGRAMME A programme available on all options to provide Beneficiaries with additional benefits for preventative care.
Only the benefits stated in the Benefit Structure under Health Booster and applicable to that particular benefit option will
be paid by the Scheme, up to a maximum rand value which is determined according to specific tariff codes.
AUTHORISATION To qualify for any Health Booster benefit, Members must:
- Contact the Client Service Centre on 0860 671 050 and obtain authorisation. (Failing to do this will result in the service
costs being deducted from day-to-day benefits.)
- Verify the tariff code or maximum rand value with the Call Centre Consultant.
- Inform the service provider involved accordingly.
SCREENING TESTS One of the benefits available on the Health Booster programme is the Health Assessment. This assessment comprises
the following screening tests:
- Body Mass Index (BMI)
- Blood sugar (finger prick test)
- Total cholesterol (finger prick test)- Blood pressure (systolic and diastolic).
Principal Members and their Adult Dependants will be entitled to one Health Assessment per calendar year and must
have the screening tests done at a KeyHealth DSP pharmacy.
A Health Assessment (HA) form can be obtained at any KeyHealth DSP pharmacy or download it from KeyHealths website
at www.keyhealthmedical.co.za.
No authorisation is required for these screening tests.
Results can be submitted by either the Member or the service provider and must be faxed to 0860 111 390.
Results of these screening tests may require follow-up tests. For this purpose, additional blood sugar andcholesterol tests are available on the Health Booster programme.
HEALTH BOOSTER
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05KEYHEALTH MARKETING BROCHURE 2012
TYPE WHO & HOW OFTEN?
PREVENTIVE CARE*
Baby immunisationChild Dependants aged 6 as required by the Departmentof Health.
Flu vaccination
Beneficiaries aged 18 once per year.
Beneficiaries aged 60 once per year.
High risk beneficiaries once per year.
Tetanus diphtheria injection All Beneficiaries as and when required.
Pneumococcal vaccination** Beneficiaries aged 60, and high risk as and when required
EARLY DETECTION TESTS*
Pap smear (Pathologist) Female Beneficiaries aged 15 once per year.
Pap smear (consultation; GP or Gynaecologist) Female Beneficiaries aged 15 once per year.
Mammogram Female Beneficiaries aged 40 once every 2 years.
General physical examination
Beneficiaries aged 30 and 59 once every 3 years.
Beneficiaries aged >59 and 69 once every 2 years.Beneficiaries aged >69 once per year.
Prostate specific antigen (Pathologist)
Male Beneficiaries aged 40 and 49 once every 5 years.Male Beneficiaries aged >49 and 59 once every 3 years.Male Beneficiaries aged >59 and 69 once every 2 years.
Male Beneficiaries aged >69 once per year.
Cholesterol test (Pathologist) Beneficiaries aged
25 once per year.Blood sugar test (Pathologist) Beneficiaries all ages once per year.
HIV/AIDS test (Pathologist) Beneficiaries aged 15 once every 5 years.
Health Assessment (HA)Body mass index, Blood pressure measurement, Cholesterol
test (finger prick), Blood sugar test(finger prick)
Adult Beneficiaries once per year.
MATERNITY*
Antenatal visits (GP or Gynaecologist) & urine test (dipstick)Female Beneficiaries. Pre-notification of and pre-authorisation
by the Scheme compulsory. Twelve (12) visits.
Scans (one before the 24th week and one thereafter)Female Beneficiaries. Pre-notification of and pre-authorisation
by the Scheme compulsory. Two (2) pregnancy scans.
Paediatrician visits Baby registered on Scheme. Two (2) visits in babys 1st year.
*Pre-authorisation essential to access benefits **Only available on Platinum, Gold and Silver options
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ESSENCE OPTIONIN-HOSPITAL
TOTAL ANNUAL BENEFIT
MST()
BENEFIT EXPLANATORY NOTES / BENEFIT SUMMARY
HOSPITALISATION, THEATRE FEES, INTENSIVE &HIGH CARE UNIT
Pre-authorisation compulsory.
Co-payment per surgical procedure
(no out-of-hospital co-payments):
Varicose vein surgery - R1 000
Umbilical hernia repair - R1 000
Facet joint injections - R1 000Functional nasal surgery - R2 000
Hysterectomy - R2 500
Rhizotomy - R2 500
Reflux surgery - R5 000
Back surgery (including spinal fusion) - R5 000
Joint replacement - R5 000
Private Hospitals
State hospitals
Unlimited; up to 100% of Agreed Tariff.
Unlimited; up to 100% of Agreed Tariff.
100% Specialist and Anaesthetist services unlimited.
Medicine on discharge 100% R275 Per admission.
PSYCHIATRIC TREATMENT 100%
R12 000
Pre-authorisation compulsory and subject to case management.
Pfpa
SUB-ACUTE FACILITIES & WOUND CARE
Wound care, hospice, private nursing,
rehabilitation and step-down facilities.
100% Pre-authorisation compulsory and subject to case management.
PMB conditions only.
BLOOD TRANSFUSION 100% Unlimited. Pre-authorisation compulsory.
ORGAN TRANSPLANT
Hospitalisation, organ harvesting and drugs for
immuno-suppressive therapy.
100% Pre-authorisation compulsory and subject to case management.
PMB conditions in DSP hospitals only.
DIALYSIS 100% Pre-authorisation compulsory and subject to case management.
PMB conditions only.
ONCOLOGY 100% R95 000 Pfpa. Pre-authorisation compulsory and subject to case
management.
RADIOLOGY
MRI and CT scans
X-rays
PET scans
100%
R 10 000
Pre-authorisation compulsory for specialised radiology, including
MRI and CT scans. Hospitalisation not covered if radiology is forinvestigative purposes only. (Day-to-day benefits will then apply.)
Pfpa. R1 000 co-payment per scan (in- or out-of-hospital),
excluding confirmed PMBs.
Unlimited.
No benefit.
PATHOLOGY 100% UnlimitedPROSTHETICS(Internal and External)
100% Pre-authorisation compulsory and subject to case management,
protocols and pricing. PMB conditions / trauma only.
HOSPITALISATION
CHRONIC
HEALTH BOOSTER
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OUT-OF-HOSPITALBENEFIT
MST()
BENEFIT EXPLANATORY NOTES / BENEFIT SUMMARY
Over-the-counter medication
Over-the-counter reading glasses
100% R445
R75
Pbpa
Pbpa; one (1) pair per year. Subject to over-the-counter
medication benefit.
PATHOLOGY No benefit, except for PMB conditions.
OPTICAL SERVICESFrames
Lenses
Eye test
Contact lenses
Refractive surgery
No benefit.
No benefit.
No benefit.
No benefit.
No benefit.
DENTISTRY
Conservative dentistry
Consultations
X-rays: Intra-oral
X-rays: Extra-oral
Oral hygiene
Fillings
Tooth extractionsRoot canal treatment
Plastic and metal frame dentures
Specialised dentistry
Maxillo-Facial and Oral surgery
Surgery in dental chair
Surgery in-hospital (general anesthesia)
Hospitalisation and Anesthetics
Hospitalisation (general anesthesia)
Laughing gas in dental rooms
IV conscious sedation in dental rooms
100%
100%
100%
100%
100%
100%
100%
100%
100%
100%
100%
Subject to DENIS protocols, Managed Care interventions and
Scheme Rules. Exclusions apply in accordance with Scheme
Rules.
One (1) check-up pbpa.
Three (3) specific (emergency) consultations pbpa.
Four (4) peri-apical radiographs pbpa.
One (1) pbp3a.
One (1) scale and polish treatment pbpa.
A treatment plan and X-rays may be required for multiple fillings.
Re-treatment of a tooth subject to clinical protocols.
No benefit.
No benefit.
No benefit.
Subject to DENIS protocols, Managed Care interventions andScheme Rules. Exclusions apply in accordance with Scheme
Rules.
DENIS pre-authorisation not required.
Wisdom teeth removal only.
DENIS pre-authorisation compulsory. (See Hospitalisation below.)
Subject to DENIS protocols, Managed Care interventions and
Scheme Rules. Exclusions apply in accordance with SchemeRules.
R1 000 co-payment per hospital admission.
DENIS pre-authorisation compulsory.
Removal of impacted wisdom teeth only.
DENIS pre-authorisation not required.
DENIS pre-authorisation compulsory.
Limited to extensive dental treatment.
PAY ALL DENTAL CO-PAYMENTS DIRECTLY TO THE SERVICE PROVIDER INVOLVED
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ESSENCE OPTION
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EQUILIBRIUM OPTIONIN-HOSPITAL
TOTAL ANNUAL BENEFIT
MST()
BENEFIT EXPLANATORY NOTES / BENEFIT SUMMARY
HOSPITALISATION, THEATRE FEES, INTENSIVE &
HIGH CARE UNIT
Pre-authorisation compulsory.
Co-payment per surgical procedure
(no out-of-hospital co-payments):
Varicose vein surgery - R1 000
Umbilical hernia repair - R1 000
Facet joint injections - R1 000
Functional nasal surgery - R2 000
Hysterectomy - R2 500
Rhizotomy - R2 500
Reflux surgery - R5 000
Back surgery (including spinal fusion) - R5 000
Joint replacement - R5 000
Private Hospitals
State hospitals
Unlimited; up to 100% of Agreed Tariff.
Unlimited; up to 100% of Agreed Tariff.
150% Specialist and Anaesthetist services unlimited.
Medicine on discharge 100% R335 Per admission.
PSYCHIATRIC TREATMENT 100%
R12 000
Pre-authorisation compulsory and subject to case management.
Pfpa. Combined benefit; in- and out-of-hospital. Sublimit of
R5 000 pfpa on out-of-hospital psychiatric treatment.
SUB-ACUTE FACILITIES & WOUND CARE
Wound care, hospice, private nursing,
rehabilitation and step-down facilities.
100% Pre-authorisation compulsory and subject to case management.
PMB conditions only.
BLOOD TRANSFUSION 100% Unlimited. Pre-authorisation compulsory.
ORGAN TRANSPLANT
Hospitalisation, organ harvesting and drugs for
immuno-suppressive therapy.
100% Pre-authorisation compulsory and subject to case management.
PMB conditions in DSP hospitals only.
DIALYSIS 100% Pre-authorisation compulsory and subject to case management.
PMB conditions only.
ONCOLOGY 100% R95 000 Pfpa. Pre-authorisation compulsory and subject to case
management.
RADIOLOGY
MRI and CT scans
X-rays
PET scans
100%
R10 000
Pre-authorisation compulsory for specialised radiology, including
MRI and CT scans. Hospitalisation not covered if radiology is for
investigative purposes only. (MSA / day-to-day benefits will then
apply.)
Pfpa. R1 000 co-payment per scan (in- or out-of-hospital),
excluding confirmed PMBs.
Unlimited.
No benefit.
PATHOLOGY 100% UnlimitedPROSTHETICS
(Internal and External)
100% Pre-authorisation compulsory and subject to case management,
protocols and pricing. PMB conditions / trauma only.
HOSPITALISATION
SAVINGS
DAY-TO-DAY
CHRONIC
HEALTH BOOSTER
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OUT-OF-HOSPITALBENEFIT
MST()
BENEFIT EXPLANATORY NOTES / BENEFIT SUMMARY
DAY-TO-DAY BENEFIT
General Practitioner and Specialist consultations.
Radiology. Prescribed and over-the-counter
medicine. Optical and auxiliary services, e.g.
physiotherapy and occupational therapy.
Over-the-counter reading glasses
100%
R75
Annual Medical Savings Account (MSA):
Principal Member: R1 116 p.a.
Adult Dependant: R672 p.a.
Child Dependant: R336 p.a.
Additional benefits limited to:
Principal Member: R1 590 p.a.
Adult Dependant: R890 p.a.
Child Dependant: R480 p.a.
Pbpa; one (1) pair per year. Subject to MSA / day-to-day benefit.
OPTICAL SERVICES
FramesLenses
Eye test
Contact lensesRefractive surgery
100%
Subject to MSA / day-to-day benefit.Subject to MSA / day-to-day benefit.
Subject to MSA / day-to-day benefit.
Subject to MSA / day-to-day benefit.No benefit. Subject to MSA.
PATHOLOGY 100% Subject to MSA / day-to-day benefit.
DENTISTRY
Conservative dentistry
Consultations
X-rays: Intra-oral
X-rays: Extra-oral
Oral hygiene
Fillings
Tooth extractions
Root canal treatment
Plastic and metal frame dentures
Specialised dentistry
Maxillo-Facial and Oral surgery
Surgery in dental chair
Surgery in-hospital (general anesthesia)
Hospitalisation and Anesthetics
Hospitalisation (general anesthesia)
Laughing gas in dental rooms
IV conscious sedation in dental rooms
100%
100%
100%
100%
100%
100%
100%
100%
100%
100%
100%
Subject to DENIS protocols, Managed Care interventions and
Scheme Rules. Exclusions apply in accordance with Scheme
Rules.
One (1) check-up pbpa.
Three (3) specific (emergency) consultations pbpa.
Four (4) peri-apical radiographs pbpa.
One (1) pbp3a.
One (1) scale and polish treatment pbpa.
A treatment plan and X-rays may be required for multiple fillings.
Re-treatment of a tooth subject to clinical protocols.
No benefit. Subject to MSA.
No benefit. Subject to MSA.
No benefit. Subject to MSA.
Subject to DENIS protocols, Managed Care interventions and
Scheme Rules. Exclusions apply in accordance with Scheme
Rules.
DENIS pre-authorisation not required.
Wisdom teeth removal only.
DENIS pre-authorisation compulsory. (See Hospitalisation below.)
Subject to DENIS protocols, Managed Care interventions and
Scheme Rules. Exclusions apply in accordance with Scheme Rules.
R1 000 co-payment per hospital admission.
DENIS pre-authorisation compulsory.
Removal of impacted wisdom teeth only.
DENIS pre-authorisation not required.
DENIS pre-authorisation compulsory.
Limited to extensive dental treatment.
PAY ALL DENTAL CO-PAYMENTS DIRECTLY TO THE SERVICE PROVIDER INVOLVED
012 KEYHEALTH MARKETING BROCHURE 2012
EQUILIBRIUM OPTION
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CHRONIC MEDICATION AND OTHER BENEFIT-CATEGORIESCHRONIC MEDICATIONCategory A (CDL)
Category B (other)
100% Unlimited subject to reference pricing.
Registration on Chronic Disease Programme compulsory.
(30% co-payment applicable when not using a DSP pharmacy.)
No benefit.
HIV/AIDS
State hospitals
100% R21 000 Pfpa. Subject to registration on HIV Programme (private hospitals,
GP visits, medication and pathology) and case management.
Unlimited.
AMBULANCE SERVICES 100% DSP - NETCARE 911
Unlimited (inter-hospital transfer subject to protocols).
MEDICAL APPLIANCES
Wheelchairs, orthopedic appliances
and incontinence equipment (including
contraceptive devices).
Hearing aids and maintenance
100%
R4500
Pre-authorisation compulsory.
Pfpa; combined in- and out-of-hospital benefit.
No benefit. Subject to MSA.
ENDOSCOPIC PROCEDURES (SCOPES)
Colonoscopy, Cystoscopy, Gastroscopy and
Sigmoidoscopy.
Hysteroscopy
Arthroscopy, Laparoscopy (diagnostic)
100% Pre-authorisation compulsory. No co-payment on out-of-hospital
scopes.
R1 500 co-payment per scope (in-hospital).
R2 000 co-payment per scope (in-hospital).
R2 500 co-payment per scope (in-hospital).
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IN-HOSPITALTOTAL ANNUAL BENEFIT
MST()
BENEFIT EXPLANATORY NOTES / BENEFIT SUMMARY
HOSPITALISATION, THEATRE FEES, INTENSIVE &
HIGH CARE UNIT
Pre-authorisation compulsory.
Co-payment per surgical procedure
(no out-of-hospital co-payments):
Varicose vein surgery - R1 000
Umbilical hernia repair - R1 000
Facet joint injections - R1 000
Functional nasal surgery - R2 000
Hysterectomy - R2 500
Rhizotomy - R2 500
Reflux surgery - R5 000
Back surgery (including spinal fusion) - R5 000
Joint replacement - R5 000
Private Hospitals
State hospitals
Unlimited; up to 100% of Agreed Tariff.
Unlimited; up to 100% of Agreed Tariff.
100% Specialist and Anaesthetist services unlimited.
Medicine on discharge 100% R165 Per admission.
PSYCHIATRIC TREATMENT 100%
R12 000
Pre-authorisation compulsory and subject to case management.
Pfpa. Combined benefit; in- and out-of-hospital. Sublimit of
R5 000 pfpa on out-of-hospital psychiatric treatment.
SUB-ACUTE FACILITIES & WOUND CARE
Hospice, private nursing, rehabilitation and
step-down facilities.
Wound Care
100%
R18 000
R5 800
Pre-authorisation compulsory and subject to case management.
Pfpa; combined in- and out-of-hospital benefit.
Pfpa sublimit.
BLOOD TRANSFUSION 100% Unlimited. Pre-authorisation compulsory.
ORGAN TRANSPLANTHospitalisation, organ harvesting and drugs for
immuno-suppressive therapy.
100% Pre-authorisation compulsory and subject to case management.PMB conditions in DSP hospitals only.
DIALYSIS 100% Pre-authorisation compulsory and subject to case management.PMB conditions only.
ONCOLOGY 100% R106 000 Pfpa. Pre-authorisation compulsory and subject to case
management.
RADIOLOGY
MRI and CT scans
X-rays
PET scans
100%
R10 000
Pre-authorisation compulsory for specialised radiology, including
MRI and CT scans. Hospitalisation not covered if radiology is for
investigative purposes only. (Day-to-day benefits will then apply.)
Pfpa. R1 000 co-payment per scan (in- or out-of-hospital),excluding confirmed PMBs.
Unlimited.
No benefit.
PATHOLOGY 100% UnlimitedPROSTHETICS
(Internal and External)
100% Pre-authorisation compulsory and subject to case management,
protocols and pricing. PMB conditions / trauma only.
SILVER OPTION
HOSPITALISATION
DAY-TO-DAY
CHRONIC
HEALTH BOOSTER
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OUT-OF-HOSPITALBENEFIT
MST()
BENEFIT EXPLANATORY NOTES / BENEFIT SUMMARY
DAY-TO-DAY BENEFIT
General Practitioner and Specialist consultations.
Radiology. Prescribed and over-the-counter
medicine. Optical and auxiliary services, e.g.
physiotherapy and occupational therapy.
Over-the-counter medicine
Over-the-counter reading glasses
100%
100% R980
R85
Limited to:
Principal Member: R4 660 p.a.
Adult Dependant: R3 390 p.a.
Child Dependant: R940 p.a.
2pfpa - additional General Practitioner consultations after
depletion of available day-to-day benefit.
Pfpa sublimit. Subject to day-to-day benefit.
Pbpa; one (1) pair per year. Subject to over-the-counter
medicine sublimit.
OPTICAL SERVICES
Frames
Lenses
Eye test
Contact lenses
Refractive surgery
100% R950
R320
R420
Pbp2a total optical benefit. Subject to day-to-day benefit and
Optical Management. Benefit confirmation compulsory.Per frame, one (1) frame pbp2a. Subject to overall optical
benefit.
One (1) pair single vision lenses pbp2a. Subject to overall opticalbenefit.
One (1) test pbp2a. Subject to overall optical benefit.
Pbpa. Subject to overall optical benefit.
No benefit.
PATHOLOGY 60% Subject to day-to-day benefit. (Co-payment payable directly to
the service provider involved.)
DENTISTRYConservative dentistry
Consultations
X-rays: Intra-oral
X-rays: Extra-oral
Oral hygiene
Fillings
Root canal treatment and tooth extractions
Plastic dentures
Specialised dentistry
Maxillo-Facial and Oral surgery
Surgery in dental chair
Surgery in-hospital (general anesthesia)
Hospitalisation and Anesthetics
Hospitalisation (general anesthesia)
Laughing gas in dental rooms
IV conscious sedation in dental rooms
100%
100%
100%
100%
100%
100%
100%
100%
100%
100%
100%
100%
Subject to DENIS protocols, Managed Care interventions and
Scheme Rules. Exclusions apply in accordance with Scheme Rules.
Two (2) check-ups pbpa.
One (1) pbp3a.
Two (2) scale and polish treatments pbpa.
A treatment plan and X-rays may be required for multiple fillings.
Re-treatment of a tooth subject to clinical protocols.
One (1) set (an upper and a lower jaw) pbp4a.
No benefit
Subject to DENIS protocols, Managed Care interventions and
Scheme Rules. Exclusions apply in accordance with Scheme Rules.
DENIS pre-authorisation not required.
Temporo-Mandibular Joint (TMJ) therapy limited to non-surgical
intervention / treatment. Claims for oral pathology procedures
(cysts, biopsies and tumour removals) only covered if supported
by a laboratory report confirming diagnosis.
DENIS pre-authorisation compulsory. (See Hospitalisation below.)
Subject to DENIS protocols, Managed Care interventions and
Scheme Rules. Exclusions apply in accordance with Scheme Rules.
R1 000 co-payment per hospital admission.DENIS pre-authorisation compulsory.
Removal of impacted wisdom teeth only.
DENIS pre-authorisation not required.
DENIS pre-authorisation compulsory.
Limited to extensive dental treatment.PAY ALL DENTAL CO-PAYMENTS DIRECTLY TO THE SERVICE PROVIDER INVOLVED
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SILVER OPTION
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CHRONIC MEDICATION AND OTHER BENEFIT-CATEGORIESCHRONIC MEDICATION
Category A (CDL)
Category B (other)
100% Unlimited subject to reference pricing.
Registration on Chronic Disease Programme compulsory.
(30% co-payment applicable when not using a DSP pharmacy.)
No benefit.
HIV/AIDS
State hospitals
100% R23 500 Pfpa. Subject to registration on HIV Programme (private hospitals,
GP visits, medication and pathology) and case management.
Unlimited.
AMBULANCE SERVICES 100% DSP - NETCARE 911
Unlimited (inter-hospital transfer subject to protocols).
MEDICAL APPLIANCES
Wheelchairs, orthopedic appliances, hearing
aids and incontinence equipment (including
contraceptive devices and maintenance of
hearing aids).
100%
R4 500
Pre-authorisation compulsory.
Pfpa; combined in- and out-of-hospital benefit.
Hearing aids subject to case management and protocols.
ENDOSCOPIC PROCEDURES (SCOPES)
Colonoscopy, Cystoscopy, Gastroscopy and
Sigmoidoscopy.
Hysteroscopy
Arthroscopy, Laparoscopy (diagnostic)
100% Pre-authorisation compulsory. No co-payment on out-of-hospital
scopes.
R1 500 co-payment per scope (in-hospital).
R2 000 co-payment per scope (in-hospital).
R2 500 co-payment per scope (in-hospital).
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HOSPITALISATION
SAVINGS
DAY-TO-DAY
CHRONIC
HEALTH BOOSTER
IN-HOSPITALTOTAL ANNUAL BENEFIT
MST()
BENEFIT EXPLANATORY NOTES / BENEFIT SUMMARY
HOSPITALISATION, THEATRE FEES, INTENSIVE &
HIGH CARE UNIT
Pre-authorisation compulsory.
Private Hospitals
State hospitals
Unlimited; up to 100% of Agreed Tariff.
Unlimited; up to 100% of Agreed Tariff.
100% Specialist and Anaesthetist services unlimited.
Medicine on discharge 100% R335 Per admission.
PSYCHIATRIC TREATMENT 100%
R24 500
Pre-authorisation compulsory and subject to case management.
Pfpa. Combined benefit; in- and out-of-hospital. Sublimit ofR10 000 pfpa on out-of-hospital psychiatric treatment.
SUB-ACUTE FACILITIES & WOUND CARE
Hospice, private nursing, rehabilitation and
step-down facilities.
Wound care
100%
R24 500
R8 000
Pre-authorisation compulsory and subject to case management.
Pfpa; combined in- and out-of-hospital benefit.
Pfpa sublimit.
BLOOD TRANSFUSION 100% Unlimited. Pre-authorisation compulsory.
ORGAN TRANSPLANT
Hospitalisation, organ harvesting and drugs for
immuno-suppressive therapy.
100% Pre-authorisation compulsory and subject to case management.
PMB conditions in DSP hospitals only.
DIALYSIS 100% Pre-authorisation compulsory and subject to case management.
PMB conditions only.
ONCOLOGY 100% R220 000 Pfpa. Pre-authorisation compulsory and subject to case
management.
RADIOLOGY
MRI and CT scans
X-rays
PET scans
100%
R10 000
Pre-authorisation compulsory for specialised radiology, including
MRI, CT and PET scans. Hospitalisation not covered if radiology is for
investigative purposes only. (MSA / day-to-day benefits will then apply.)
Pfpa. R1 000 co-payment per scan (in- or out-of-hospital),
excluding confirmed PMBs.
Unlimited.
Unlimited number of scans. Limited to R11 000 per scan.
PATHOLOGY 100% Unlimited
PROSTHETICS
(Internal and External)
100% R22 500 Pfpa, combined benefit. Pre-authorisation compulsory and
subject to case management, protocols and pricing.
GOLD OPTION
019KEYHEALTH MARKETING BROCHURE 2012
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OUT-OF-HOSPITALBENEFIT
MST()
BENEFIT EXPLANATORY NOTES / BENEFIT SUMMARY
DAY-TO-DAY BENEFIT
General Practitioner and Specialist consultations.
Radiology. Prescribed and over-the-counter
medicine. Optical and auxiliary services, e.g.
physiotherapy and occupational therapy.
Over-the-counter medicine
Over-the-counter reading glasses
100%
100% R1 200
R105
Annual Medical Savings Account (MSA):
Principal Member: R3 096 p.a.
Adult Dependant: R2 088 p.a.
Child Dependant: R600 p.a.
Additional benefits limited to:
Principal Member: R2 540 p.a.
Adult Dependant: R1 890 p.a.
Child Dependant: R600 p.a.
Pfpa sublimit. Subject to MSA / day-to-day benefit.
Pbpa; one (1) pair per year. Subject to the over-the-counter
medicine sublimit.OPTICAL SERVICES
Frames
Lenses
Eye test
Contact lenses
Refractive surgery
100% R1 900
R600
R900
Pbp2a total optical benefit. Subject to MSA / day-to-day benefit
and Optical Management. Benefit confirmation compulsory.
Per frame, one (1) frame pbp2a. Subject to overall opticalbenefit.
One (1) pair pbp2a. Subject to overall optical benefit.
One (1) test pbp2a. Subject to overall optical benefit.
Pbpa. Subject to overall optical benefit.
Pre-authorisation compulsory - subject to overall optical limit.
PATHOLOGY 60% Subject to MSA / day-to-day benefit. (Co-payment payable
directly to the service provider involved.)
DENTISTRY
Conservative dentistry
Consultations
X-rays: Intra-oral
X-rays: Extra-oral
Oral hygiene
Fillings
Root canal treatment and tooth extractions
Plastic dentures
Specialised dentistry
Partial metal frame dentures
Crowns and bridges
Implants
Orthodontics
Periodontics
100%
100%
100%
100%
100%
100%
100%
80%
80%
80%
80%
Subject to DENIS protocols, Managed Care interventions and
Scheme Rules. Exclusions apply in accordance with Scheme Rules.
Two (2) check-ups pbpa.
One (1) pbp3a. (Additional benefit may be granted where
specialised dental treatment planning / follow-up is required.)
Two (2) scale and polish treatments pbpa.
A treatment plan and X-rays may be required for multiple fillings.
Re-treatment of a tooth subject to clinical protocols.
One (1) set (an upper and a lower jaw) pbp4a.
Subject to DENIS protocols, Managed Care interventions and
Scheme Rules. Exclusions apply in accordance with Scheme Rules.
One (1) partial metal frame (an upper or a lower jaw) pbp5a.
DENIS pre-authorisation compulsory.
A treatment plan and X-rays may be requested.
One (1) per tooth pbp5a.
No benefit. Subject to MSA.
DENIS pre-authorisation compulsory.
Cases will be clinically assessed using orthodontic indices.
Where function is impaired.
Not for cosmetic reasons; laboratory costs also excluded.
Only one (1) Beneficiary per family may commence treatment
per calendar year.
Limited to Beneficiaries younger than 18 years.
DENIS pre-authorisation compulsory.Limited to conservative, non-surgical therapy (root planing)
only and will be applied to Beneficiaries registered on the Perio
Programme.
020 KEYHEALTH MARKETING BROCHURE 2012
GOLD OPTION
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CHRONIC MEDICATION AND OTHER BENEFIT-CATEGORIESCHRONIC MEDICATION
CategoryA(CDL)
CategoryB (other)
100% Unlimited subject to reference pricing.
Registration on Chronic Disease Programme compulsory.
(15% co-payment applicable when using a non-DSP pharmacy.)
No benefit.
HIV/AIDS
State hospitals
100% R29 000 Pfpa. Subject to registration on HIV Programme (private hospitals,
GP visits, medication and pathology) and case management.
Unlimited.
AMBULANCE SERVICES 100% DSP - NETCARE 911
Unlimited (inter-hospital transfer subject to protocols).
MEDICAL APPLIANCES
Wheelchairs, orthopedic appliances and
incontinence equipment
(including contraceptive devices).
100%
R5 500
Pre-authorisation compulsory.
Pfpa; combined in- and out-of-hospital benefit.
HEARING AIDS
Hearing aids
Maintenance (batteries included)
100%
R5 800
R600
No authorisation required.
Pfp4a.
Pbpa.
ENDOSCOPIC PROCEDURES (SCOPES)
Colonoscopy, Cystoscopy, Gastroscopy and
Sigmoidoscopy.
Hysteroscopy
Arthroscopy, Laparoscopy (diagnostic)
100% Pre-authorisation compulsory. No co-payment on out-of-hospitalscopes.
R1 500 co-payment per scope (in-hospital).
R2 000 co-payment per scope (in-hospital).
R2 500 co-payment per scope (in-hospital).
021KEYHEALTH MARKETING BROCHURE 2012
OUT-OF-HOSPITALBENEFIT
MST()
BENEFIT EXPLANATORY NOTES / BENEFIT SUMMARY
[DENTISTRYContinued]
Maxillo-Facial and Oral surgery
Surgery in dental chair
Surgery in-hospital (general anesthesia)
Hospitalisation and Anesthetics
Hospitalisation (general anesthesia)
Laughing gas in dental rooms
IV conscious sedation in dental rooms
100%
100%
100%
100%
100%
Subject to DENIS protocols, Managed Care interventions and
Scheme Rules. Exclusions apply in accordance with Scheme Rules.
DENIS pre-authorisation not required.
Temporo-Mandibular Joint (TMJ) therapy limited to non-surgical
intervention/treatment. Claims for oral pathology procedures
(cysts, biopsies and tumour removals) only covered if supported
by a laboratory report confirming diagnosis.
DENIS pre-authorisation compulsory. (See Hospitalisation below.)
Subject to DENIS protocols, Managed Care interventions and
Scheme Rules. Exclusions apply in accordance with Scheme Rules.
R1 000 co-payment per hospital admission. DENISpre-authorisation compulsory.
Extensive dental treatment for very young Child Dependants.
Removal of impacted wisdom teeth.
DENIS pre-authorisation not required.
DENIS pre-authorisation compulsory.
Limited to extensive dental treatment.
PAY ALL DENTAL CO-PAYMENTS DIRECTLY TO THE SERVICE PROVIDER INVOLVED
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022 KEYHEALTH MARKETING BROCHURE 2012
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PLATINUM OPTION
HOSPITALISATION
DAY-TO-DAY
CHRONIC
HEALTH BOOSTER
023KEYHEALTH MARKETING BROCHURE 2012
IN-HOSPITALTOTAL ANNUAL BENEFIT
MST()
BENEFIT EXPLANATORY NOTES / BENEFIT SUMMARY
HOSPITALISATION, THEATRE FEES, INTENSIVE &
HIGH CARE UNIT
Pre-authorisation compulsory.
Private Hospitals
State hospitals
Unlimited; up to 100% of Agreed Tariff.
Unlimited; up to 100% of Agreed Tariff.
100% Specialist and Anaesthetist services unlimited.
Medicine on discharge 100% R385 Per admission.
PSYCHIATRIC TREATMENT 100%
R36 000
Pre-authorisation compulsory and subject to case management.
Pfpa. Combined in- and out-of-hospital. Sublimit ofR15 000 pfpa on out-of-hospital psychiatric treatment.
SUB-ACUTE FACILITIES & WOUND CARE
Hospice, private nursing, rehabilitation and
step-down facilities.
Wound care
100%
R30 000
R10 500
Pre-authorisation compulsory and subject to case management.
Pfpa; combined in- and out-of-hospital benefit.
Pfpa sublimit.
BLOOD TRANSFUSION 100% Unlimited. Pre-authorisation compulsory.
ORGAN TRANSPLANT
Hospitalisation, organ harvesting and drugs for
immuno-suppressive therapy.
100% Unlimited. Pre-authorisation compulsory and subject to case
management.
DIALYSIS 100% Unlimited. Pre-authorisation compulsory and subject to case
management.
ONCOLOGY 100% Unlimited. Pre-authorisation compulsory and subject to case
management.
RADIOLOGY
MRI and CT scans
X-rays
PET scans
100%
R15 000
Pre-authorisation compulsory for specialised radiology, including
MRI, CT and PET scans. Hospitalisation not covered if radiology is
for investigative purposes only. (Day-to-day benefits will then apply.)
Pfpa. R1 000 co-payment per scan (in- or out-of-hospital),
excluding confirmed PMBs.
Unlimited.
Unlimited number of scans. Limited to R11 000 per scan.
PATHOLOGY 100% Unlimited
PROSTHETICS
(Internal and External)
100%
80%
R55 000 Pfpa, combined benefit. Pre-authorisation compulsory and
subject to case management, protocols and pricing.
20% co-payment when limit is exceeded.
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024 KEYHEALTH MARKETING BROCHURE 2012
PLATINUM OPTION
OUT-OF-HOSPITALBENEFIT
MST()
BENEFIT EXPLANATORY NOTES / BENEFIT SUMMARY
DAY-TO-DAY BENEFIT
General Practitioner and Specialist consultations.
Radiology. Prescribed and over-the-counter
medicine. Optical and auxiliary services, e.g.
physiotherapy and occupational therapy.
Over-the-counter medicine
Over-the-counter reading glasses
100%
90%
90%
100% R1 800
R125
Limited to:
Principal Member: R6 550 p.a.
Adult Dependant: R6 350 p.a.
Child Dependant: R1 550 p.a.
Self-funding gap : (MST) PM: R2 290 AD: R2 040 CD: R750
Threshold: co-payment on all services in threshold zone
Prescribed medicine: sublimit in threshold zone of
PM: R5 400 AD: R2 450 CD: R1 200
Pfpa sublimit. Subject to day-to-day and threshold.
Pbpa; one (1) pair per year. Subject to the over-the-counter
medicine sublimit.OPTICAL SERVICES
Frames
Lenses
Eye test
Contact lenses
Refractive surgery
100% R3 200
R950
R1 500
R6 400
Pbp2a total optical benefit. Subject to day-to-day benefit,
threshold and Optical Management. Benefit confirmation
compulsory.Per frame, one (1) frame pbp2a. Subject to overall optical
benefit.
One (1) pair pbp2a. Subject to overall optical benefit.
One (1) test pbp2a. Subject to overall optical benefit.
Pbpa.
Pbp2a. Pre-authorisation compulsory.
PHYSIOTHERAPY 100% R8 500 Pfpa sublimit. Subject to day-to-day benefit and threshold.
PATHOLOGY 80% R8 500 Pfpa sublimit. Subject to day-to-day benefit and threshold.
(Co-payment payable directly to the service provider involved.)
DENTISTRY
Conservative dentistry
Consultations
X-rays: Intra-oral
X-rays: Extra-oral
Oral hygiene
Fillings
Root canal treatment and tooth extractions
Plastic dentures
Specialised dentistry
Partial metal frame dentures
Crowns and bridges
Implants
Orthodontics
Periodontics
100%
100%
100%
100%
100%
100%
100%
80%
80%
80%
80%
80%
R2 700
Subject to DENIS protocols, Managed Care interventions and
Scheme Rules. Exclusions apply in accordance with Scheme Rules.
Two (2) check-ups pbpa.
One (1) pbp3a. (Additional benefit may be granted where
specialised dental treatment planning / follow-up is required.)
Two (2) scale and polish treatments pbpa.
A treatment plan and X-rays may be required for multiple fillings.
Re-treatment of a tooth subject to clinical protocols.
One (1) set (an upper and a lower jaw) pbp4a.
Subject to DENIS protocols, Managed Care interventions andScheme Rules. Exclusions apply in accordance with Scheme Rules.
Two (2) frames (an upper and a lower jaw) pbp5a.
DENIS pre-authorisation compulsory.A treatment plan and X-rays may be requested.
One (1) per tooth pbp5a.
Pbpa limitation on cost of implant components. DENIS
pre-authorisation compulsory.
DENIS pre-authorisation compulsory.
Cases will be clinically assessed using orthodontic indices.
Where function is impaired.
Not for cosmetic reasons; laboratory costs also excluded.
Only one (1) Beneficiary per family may commence treatment
per calendar year.
Limited to Beneficiaries younger than 18 years.
DENIS pre-authorisation compulsory.
Limited to conservative, non-surgical therapy (root planing)
only and will be applied to Beneficiaries registered on the PerioProgramme.
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025KEYHEALTH MARKETING BROCHURE 2012
CHRONIC MEDICATION AND OTHER BENEFIT-CATEGORIESCHRONIC MEDICATION
CategoryA(CDL)
CategoryB (other)
100%
90% R11 500
Unlimited subject to reference pricing.
Registration on Chronic Disease Programme compulsory.
(10% co-payment applicable when using a non-DSP pharmacy.)
Pbpa, with a maximum of R23 500 pfpa.
10% co-payment applicable when using a non-DSP / pharmacy.
10% co-payment not applicable to PMB conditions.
(Co-payment payable directly to the service provider involved.)
HIV/AIDS
State hospitals
100% R35 000 Pfpa. Subject to registration on HIV Programme (private hospitals,
GP visits, medication and pathology) and case management.
Unlimited.
AMBULANCE SERVICES 100% DSP - NETCARE 911
Unlimited (inter-hospital transfer subject to protocols).
MEDICAL APPLIANCES
Wheelchairs, orthopedic appliances and
incontinence equipment
(including contraceptive devices).
100%
R7 000
Pre-authorisation compulsory.
Pfpa; combined in- and out-of-hospital benefit.
HEARING AIDS
Hearing aids
Maintenance (batteries included)
100%
R11 500
R800
No authorisation required.
Pfp4a.
Pbpa.
ENDOSCOPIC PROCEDURES (SCOPES)
Colonoscopy, Cystoscopy, Gastroscopy and
Sigmoidoscopy.
Hysteroscopy
Arthroscopy, Laparoscopy (diagnostic)
100% Pre-authorisation compulsory. No co-payment on out-of-hospital
scopes.
R1 500 co-payment per scope (in-hospital).
R2 000 co-payment per scope (in-hospital).
R2 500 co-payment per scope (in-hospital).
OUT-OF-HOSPITALBENEFIT
MST()
BENEFIT EXPLANATORY NOTES / BENEFIT SUMMARY
[DENTISTRYContinued]
Maxillo-Facial and Oral surgery
Surgery in dental chair
Surgery in-hospital (general anesthesia)
Hospitalisation and Anesthetics
Hospitalisation (general anesthesia)
Laughing gas in dental rooms
IV conscious sedation in dental rooms
100%
100%
100%
100%
100%
Subject to DENIS protocols, Managed Care interventions and
Scheme Rules. Exclusions apply in accordance with Scheme Rules.
DENIS pre-authorisation not required.
Temporo-Mandibular Joint (TMJ) therapy limited to non-surgical
intervention/treatment. Claims for oral pathology procedures
(cysts, biopsies and tumour removals) only covered if supported
by a laboratory report confirming diagnosis.
DENIS pre-authorisation compulsory. (See Hospitalisation below.)
Subject to DENIS protocols, Managed Care interventions and
Scheme Rules. Exclusions apply in accordance with Scheme Rules.
R1 000 co-payment per hospital admission.
Extensive dental treatment for very young Child Dependants.
Removal of impacted wisdom teeth.
DENIS pre-authorisation compulsory.
DENIS pre-authorisation not required.
DENIS pre-authorisation compulsory.
Limited to extensive dental treatment.
PAY ALL DENTAL CO-PAYMENTS DIRECTLY TO THE SERVICE PROVIDER INVOLVED
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026 KEYHEALTH MARKETING BROCHURE 2012
2012 MONTHLY CONTRIBUTIONS
ESSENCEPrincipal Member Adult Dependant Child Dependant
Monthly contribution R899 R543 R275
EQUILIBRIUMPrincipal Member Adult Dependant Child Dependant
Monthly contribution R1 070 R645 R327
Monthly savings R 93 R56 R28
Total monthly contribution R1 163 R701 R355
SILVERPrincipal Member Adult Dependant Child Dependant
Monthly contribution R1 937 R1 041 R402
GOLDPrincipal Member Adult Dependant Child Dependant
Monthly contribution R2 326 R1 571 R455
Monthly savings R258 R174 R50
Total monthly contribution R2 584 R1 745 R505
PLATINUMPrincipal Member Adult Dependant Child Dependant
Monthly contribution R4 061 R2 846 R855
WHAT IS NOT COVERED BY THE SCHEME?With the exception of PMBs and unless specific provision has been made for benefits in the Scheme Rules, no benefitswill be payable in respect of the following (for a complete list of the Scheme exclusions, please visit the Schemeswebsite at www.keyhealthmedical.co.za.):
Examinations, consultations, treatment, operations and procedures relating to:
Acupuncture
BiokineticsBiostress assessmentsColonic irrigations
Cosmetic proceduresDNA testingEBCT Electronic Beam Computed Tomography (coronary and heart)
GastroplastyIQ tests and learning problemsLaser-assisted functional reconstruction of palate and uvula, including follow-up proceduresObesity
Reversals of sterilisationsReversals of vasectomies
Sclerotherapy of varicose veins
Certain charges and purchases (e.g. humidifiers and blood pressure monitors), as referred to in the Scheme Rules, mayalso be excluded.
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027KEYHEALTH MARKETING BROCHURE 2012
PRESCRIBED MINIMUM BENEFITS (PMBs)
WHAT ARE PMBs?
In terms of the Medical Schemes Act, Act 131 of 1998, medicalschemes must provide minimum hospital-based benefits forcertain conditions. These hospital benefits are available evenduring a waiting and/or exclusion period. These prescribedminimum benefits cover members for specific treatments andservices, available in a State hospital. A list of the conditionscovered in-hospital is available on the website of the Councilfor Medical Schemes, atwww.medicalschemes.com.
PMBs are defined by the Medical Schemes Act with the aimof ensuring that all medical scheme members have accessto certain minimum health benefits, regardless of the Schemebenefit option they have selected, their age or the state oftheir health.
In terms of the Act, medical schemes have to cover the costsrelated to the diagnosis, treatment and care of:
- all emergency medical conditions; and- a limited set of approximately 270 medical conditions as
defined in the Diagnosis Treatment Pairs, which includes25 chronic conditions as defined in the Chronic DiseaseList.
The treating Doctor decides whether a condition is aPMB or not by taking into account the symptoms only a diagnosis-based approach.
Conditions that are covered In Annexure A of the Regulations to the Medical
Schemes Act, the complete list of PMBs is provided in
the form of Diagnosis and Treatment Pairs. The approximately 270 conditions qualifying for PMB
cover are diagnosis-specific and include a large numberof diverse conditions, broadly divided into 15 categories.
The Scheme makes use of formularies for chronic medicationto manage costs and ensure accessibility to appropriatecare for all Members. A formulary is an approved list ofmedication applicable to the chronic conditions covered bythe Scheme.
These formularies do not in any way compromise the quality ofhealthcare that a Member will receive.
DSPs for PMBs
Any services falling within the prescribed minimum benefitsrendered by the Schemes DSPs will be covered in full. TheScheme has appointed the following DSPs:
- The National Hospital Network (NHN);- The State (Gauteng, Free State and Western Cape) as
the DSP for any major medical services which fallwithin PMBs. In the absence of any formal agreement,any other hospital will be regarded as a DSP.
- CareCross Specialist Network
Subject to application and approval, the Scheme will pay100% of MST in respect of any services for prescribed minimumbenefits which are voluntarily obtained by a Beneficiary from aservice provider, other than the DSP.
Subject to application and approval, any services in respect ofPMBs, which are involuntarily obtained by the Beneficiary from a
service provider other than the DSP, will be covered in full.
TABLE 1(CATEGORY A):PRESCRIBED MINIMUM BENEFIT
CHRONIC DISEASE LIST (CDL)
(ALL OPTIONS)
TABLE 2 (CATEGORY B): OTHER
CHRONIC CONDITIONS
(PLATINUM OPTION ONLY)
1. Addison's disease 1. Acne
2. Asthma 2. Allergic rhinitis
3. Bipolar mood disorder 3. Alzheimer's disease
4. Bronchiectasis 4. Ankylosing spondylitis
5. Cardiac failure 5. Benign prostatic
hypertrophy
6. Cardiomyopathy
disease
6. Clotting disorders*
7. Chronic renal disease 7. Cystic fibrosis
8. Coronary artery disease 8. Deep vein thrombosis*
9. Crohn's disease 9. Diverticulitis and irritable
bowel syndrome
10. Chronic obstructive
pulmonary disorder
10. Gastro-esophageal reflux
disease
11. Diabetes insipidus 11. Hypoparathyroidism*
12. Diabetes melli tus type 1 12. Hyperkinesis (Attention
deficit disorder)
13. Dysrhythmias 13. Hyperthyroidism
14. Epilepsy 14. Interstitial fibrosis
15. Glaucoma 15. Iron deficiency anemia
16. Haemophilia 16. Major depression*
17. Hyperlipidaemia 17. Meniere's disease
18. Hypertension 18. Menopausal disorder
(calcium only)*
19. Hypothyroidism 19. Migraine
20. Hormone replacement
therapy (HRT)#
20. Myasthenia gravis
21. Multiple sclerosis 21. Osteoarthritis
22. Parkinson's disease 22. Osteoporosis
23. Rheumatoid arthritis 23. Paraplegia, quadriplegia*
24. Schizophrenia 24. Peripheral vascular
disease*
25. Systemic lupus
erythematosis
25. Psoriasis
26. Ulcerative colitis 26. Rheumatic fever
27. Stroke*
28. Testosterone deficiency
29. Urinary incontinence
Table 1 - # Indicates an additional chronic condition approved by the Scheme (all options).Table 2 - PMB conditions indicated by *.Table 2 - A 10% co-payment applicable when using a non-DSP / pharmacyTable 2 - A 10% co-payment not applicable to PMB conditions.
Please refer towww.keyhealthmedical.co.za for any possible changes to this list.
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OBTAIN AUTHORISATION FOR HOSPITALISATION
Before admission to hospital, it is a requirement thatBeneficiaries phone 0860 671 060 (Authorisation Call Centre)for authorisation. The following information must be providedwhen calling:
1. Membership number;2. Full name of the patient being hospitalised;3. Name and practice number of the hospital to which the
patient will be admitted;4. Reason for the hospital admission or the
planned diagnostic procedure(s) and the relevantICD-10 or CPT4 code(s);
5. Date of admission and the date on which theprocedure(s) is/are scheduled to be carried out; and
6. Particulars of the Doctor or service provider(practice number, initials, surname andtelephone number).
Always ask your Doctor for full details of:
The reason for admission; The associated medical diagnosis; and The prospective procedure(s) as well as the
procedure code(s) to be used.
Once the above-mentioned information has been processed,the Beneficiary will be provided with an authorisation number.If no authorisation number is obtained, no benefits will bepayable. Please note that a Beneficiary needs to obtainauthorisation within 24 hours prior to an admission, or withintwo (2) working days after an emergency admission (a familymember, friend or the hospital can call on the Beneficiarysbehalf if he/she is unable to do so), otherwise no benefits willbe paid.
REGISTER CHRONIC ILLNESS CONDITIONS
Authorisation for chronic medication is subject to thefollowing:
The treating Doctor or the Pharmacist must registerchronic conditions with MediKredit on 0800 132 345
as detailed clinical information, including theconditions ICD-10 code and severity status, is required.
The Doctor will then issue a prescription to obtainthe medication from a local pharmacy, a SchemeDSP pharmacy or the Doctor s dispensary.
Certain products will only be authorised if prescribedby an appropriate Specialist. These Specialistsmust contact MediKredit on 0800 132 345 forfurther information.
CLAIM FROM THE SCHEME
The Scheme strives to make the claims procedure as user-friendly as possible. In most cases, claims are submitted
on Members behalf by the service provider (Doctor,Dentist, Physiotherapist, Pharmacist, etc.). The Scheme mustemphasise, however, that Members should check all the claim
028 KEYHEALTH MARKETING BROCHURE 2012
HOWTO?entries on their claims statements to ensure that the serviceswere indeed rendered. By doing this, Members will notice anyinaccurate claims against their benefits. If there appears tobe a problem, Members must contact the service providerand enquire about the claims submitted on their behalf. If anyservices charged for were not rendered, alert the Scheme.In this way, Members will help ensure that the Scheme paysonly for the services received. If the Scheme has a memberse-mail address on its system, an electronic notification willbe sent each time a claim is processed. This will further helpMembers to manage their medical expenses.
USE THE E-MAIL FACILITY
Webmail is a simple e-mail-based interface for Members togain access to their Medical Scheme information withouthaving to phone the Client Service Centre.
A Member can activate webmail by e-mailing the Scheme [email protected]. No details arerequired in the subject field or the body of the mail. The e-mailaddress of the Member will be authenticated againstthe e-mail address loaded on the system. If an e-mail addresshas not been loaded onto the system, or if there ismore than one Member using the same e-mail address,the Member will receive a response informing him/her thatKeyHealth is unable to authenticate the e-mail address and istherefore unable to generate the webmail.
Once an e-mail address has been authenticated, the systemwill respond by e-mailing the Member a complete packageof information. This package includes:
Membership details Case history Claims history Benefits Contributions Claims advice
USE THE SMS FACILITY
Members may gain access to useful information 24 hours aday by sending an SMS to 32899. The options are as follows:
Send an SMS with the letter B in the message field toreceive an SMS with current benefits available.
Send an SMS with the letter C in the message field toreceive an e-mail with claims, as per last statement.
Send an SMS with the letter D in the message field toreceive an SMS with membership details.
Send an SMS with the letters IC and the relevantICD-10 code in the message field to receive an SMSwith the ICD10 code description details.
Members should receive a reply within minutes, provided that
their cell number/e-mail address is up to date on the system.
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029KEYHEALTH MARKETING BROCHURE 2012
GLOSSARYAgreed tariff A tariff agreed to from time to time between the Scheme and service providers, e.g. hospital
groups.
Chronic Disease List (CDL) A list of chronic illness conditions that is covered in terms of legislation.
Day-to-day benefit A combined out-of-hospital limit which may be used by any beneficiary in respect of GeneralPractitioners, Specialists, radiology, optical, pathology, prescribed medicine and auxiliary services
and which may include a sub-limit for self-medication.
DENIS (Dental Information Systems) A service provider contracted by the Scheme to manage dental benefits on behalf of the Scheme
according to protocols.
Designated Service Provider (DSP) A provider that renders healthcare services to members at an agreed tariff and has to be used to
qualify for certain benefits.
Emergency An emergency medical condition means the sudden and un-expected onset of a health condition
that requires immediate medical treatment and/or an operation. If the treatment is not available,
the emergency could result in weakened bodily functions, serious and lasting damage to organs,
limbs or other body parts, or even death.
Health Booster An additional benefit for preventative health care.
Medical Scheme Tariff (MST) Also referred to as KeyHealth tariff. A set of tariffs the Scheme pays for services rendered by service
providers.
Optical Management A cost and quality optical management programme provided by Opticlear.
Physical Trauma A severe bodily injury due to violence or an accident, e.g. gunshot, knife wound, fracture or motor
vehicle accident. Serious and life-threatening physical injury, potentially resulting in secondary
complications such as shock, respiratory failure and death. This includes penetrating, perforating
and blunt force trauma.
OTC Over-The-Counter (medicine or glasses)
MSA Medical Savings Account
pbpa per beneficiary per annum (per year)
pbp2a per beneficiary biennially [every two (second) year(s)]
pfpa per family per annum (per year)
pfp2a per family biennially [every two (second) year(s)]
2pfpa two (2) per family per annum (per year)
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030 KEYHEALTH MARKETING BROCHURE 2012
NOTES
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* Disclaimer: Although every precaution has been taken to ensure the accuracy of information contained in this brochure, the official rules of the Scheme will prevail, should a dispute arise.The rules of KeyHealth are available on request or can be viewed at www.keyhealthmedical.co.za.
* Benefits are subject to approval by the Council for Medical Schemes.
VERSION 1
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* Disclaimer: Although every precaution has been taken to ensure the accuracy of information contained in this brochure, the official rules of the Scheme will prevail, should a dispute arise.The rules of KeyHealth are available on request or can be viewed at www.keyhealthmedical.co.za.
* Benefits are subject to approval by the Council for Medical Schemes.
VERSION 1
* Disclaimer: Although every precaution has been taken to ensure the accuracy of information contained in this brochure, the official rules of the Scheme will prevail, should a dispute arise.The rules of KeyHealth are available on request or can be viewed at www.keyhealthmedical.co.za.
* Benefits are subject to approval by the Council for Medical Schemes.
VERSION 1
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www.keyhealthmedical.co.za
Client Service Centre 0860 67 1050e-mail [email protected] Fax: 0860 111 390
Netcare 911 082 911
Hospital pre-authorisation 0860 67 1060
e-mail [email protected] Fax: 012 679 4471
Oncology management
programme0860 67 1060
e-mail [email protected] Fax : 012 679 4469
DENIS (dental)
pre-authorisation0860 10 4926
e-mail [email protected] Fax : 0866 770 336
DENIS ( dental) claims enquiries / Submissions
e-mail [email protected]
Lifesense disease management 0860 50 6080
Crisis line ( Netcare 911) 082 911
Chronic medication registration
(to be used by providers)0800 13 2345
Optical management 0861 67 8427
Fax : 0861 100 397
Fraud line 0860 11 0820
e-mail [email protected]
New Business 012 667 5100
e-mail [email protected] Fax: 0866 050 656
Membership 0860 67 1050
[email protected] : 0860 111 390
Broker queries (Client Service Centre) 0860 67 1050
e-mail [email protected]
Website www.keyhealthmedical.co.za
Postal address:
P.O. Box 14145
Lyttelton
0140
CONTACT US