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Discovery Health KeyCare Plus R11551 and Over 2017

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Type of Medical Aid Plan: 
Capitation
Medical Aid Year: 
2017
Income Level: 
11 551+
In Hospital Benefits
Are you prepared to use designated hospitals?: 
Yes
Hospital Rate of Payment: 
100%
Hospitals: 

100% in Full Cover Hospital Network, up to 70% of scheme tariff in Partial Cover Hospital Network.

Upfront Payments to hospitals: 

None

Casualty / Emergency Visits: 
Any casualty unit in Keycare network. Client pays first R300.
Specialists: 
100% of scheme tariff
Other healthcare professionals eg. Physio, Occupational, Dietician: 
100% of scheme tariff
Radiology and pathology: 
100% of scheme rate
Scopes (gastroscopy, colonoscopy, sigmoidoscopy and proctoscopy): 
100% scheme rate
MRI and CT scans: 
100% of scheme rate
ICU and High Care: 
Unlimited 100 % of scheme rate at Network hospital
Dialysis: 
Unlimited 100 % of scheme rate at Network hospital
Organ Transplants: 
Subject to pre-authorisation and clinical protocols Unlimited 100 % of scheme rate
Oncology / Cancer: 
100 % of scheme rate Network provider
Neck and Back Operations: 
PMB's only
Joint Replacements: 
PMB's only
Prosthesis: 

No benefit.

Medical and Surgical Appliances: 
Certain medical equipment (e.g. wheelchair and crutches) covered at R5 200 per family per year. Must be obtained from network provider.
Maternity Confinements: 
Pre-authorisation required. 100% cover at Network hospital. Elective cesarean section excluded. Only considered if medically necessary and motivated.
In Hospital Dentistry: 
No benefit.
Take home Medicine: 
100 % of scheme rate
Rehabilitation, Hospice and Step-down facilities: 
100% of scheme rate
Treatment for Mental Health: 
21 days admissions or up to 15 out-of-hospital consultations per person
HIV / AIDS: 
100 % of scheme rate
Ambulance Service: 
Netcare 911
International Travel Benefit: 
No Benefit.
Day-to-day benefits
GP consultations: 

Unlimited Doctor consultations at chosen Keycare Doctor. Pre-authorisation required after 15th Keycare Doctor visit. 4 out-of-network Keycare doctor visits.

Specialist consultations: 

Specialist cover up to a limit of R3 570 per person.

Acute medicine: 

Dispensed by dispensing Keycare doctor. If purchased elsewhere for client's own account.

Over-the-counter (OTC) Medicine: 

Day-to-day medicine: We pay for medicine from our medicine list if they are prescribed by your chosen KeyCare network GP.

Optometry benefits: 
One eye test, glasses and a frame (up to a limited amount) per person at an optometrist in the Network.
Basic dentistry: 
Consultations, fillings and tooth extractions at a Keycare dentist.
Specialised Dentistry: 
No Benefit.
Orthodontics: 

No Benefit.

MRI and CT Scans (Out of Hospital): 
No benefit.
Radiology and Pathology: 
Basic X-rays at Network provider. Must be referred by Keycare doctor.
Pregnancy benefits: 
100% of scheme rate: 4 doctor visits (or gynaecologist or midwife), 1 routine scan (between weeks 10 and 20), Selected blood tests at Keycare doctor or gynaecologist.
Physiotherapy and Occupational Therapy day to day: 
No benefit.
Chronic Conditions
Provider: 
Clicks and Dis-Chem
Chronic Conditions: 

26 Conditions on Chronic Disease List. PMB only

Additional Chronic Conditions: 
No Benefit.
Preventative Care Benefits
Preventative Benefits: 

Certain tests at wellness network provider: blood glucose, blood pressure, cholesterol, body mass index, HIV screening test. Mammogram every 2 years, Pap smear every 3 years, prostate screening every 3 years.

Total Contributions
Total Contribution Main Member: 
1906.00
Total Contribution Adult: 
1906.00
Total Contribution Child*: 
510.00
Plus
Risk Contributions
Risk Contribution Main Member: 
1906.00
Risk Contribution Adult: 
1906.00
Risk Contribution Child: 
510.00
Benefit: 
Cancer treatment, if PMB, in network or state facility. Any other provider, only 80% of Scheme Rate covered.
How many times per annum do you and your dependants visit a doctor?: 
15
How much do you spend on Acute medication per annum?: 
R1000 - R4999
How much do you spend on Chronic medication per annum?: 
R1000 - R4999
Will you or any of your dependants require specialised Dentistry: 
No