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KeyCare Core R13 801 + - 2021

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Type of Medical Aid Plan: 
Capitation
Medical Aid Year: 
2021
Income Level: 
13800 +
Day to day Benefits: 

Specialist Benefit only, up to R4 400 per person per annum

In Hospital Benefits
Are you prepared to use designated hospitals?: 
Yes
Hospital Rate of Payment: 
Unlimited at 100% of Discovery Health Rate (DHR). If you use a Partial Cover Hospital Discovery pays 70% of cost. If the admission is a PMB, Discovery pays 80% of cost. No cover if you use a hospital outside of the KeyCare Network
Hospitals: 

KeyCare Network Hospital or KeyCare Partial Cover Hospital. A defined list of procedures are covered in the KeyCare Day Surgery Network

Upfront Payments to hospitals: 

If you use a KeyCare Partial Cover Hospital, you will have to pay 30% of the cost for a planned admission and 20% of the cost for a PMB admission

Casualty / Emergency Visits: 
No benefit
Specialists: 
Full cover for network specialists. 100% of DHR if not in the network
Other healthcare professionals eg. Physio, Occupational, Dietician: 
100% of DHR
Radiology and pathology: 
100% of DHR
Scopes (gastroscopy, colonoscopy, sigmoidoscopy and proctoscopy): 
PMB only in KeyCare Day Surgery Network. Authorised scopes done in dr's rooms will be covered from the hospital benefit
MRI and CT scans: 
If part of an approved admission 100% of DHR. If not related to admission or for back and neck treatment, paid from the Specialist Benefit up to the limit of R4 400 pppa
ICU and High Care: 
100% of DHR
Dialysis: 
When registered, a network provider will be allocated to you or you can go to a state facility. if you go elsewhere Discovery will pay up to 80% of DHR
Organ Transplants: 
Cover for transplant surgery explained on authorisation request. Discovery pay for appropriate, approved work-up costs for recipient, procurement of organ and necessary tests done on donor before harvesting organ, even if donor is not a member of DH
Oncology / Cancer: 
Subject to registration on the Oncology Care Programme and treatment in the network. Cover is for a 12 month cycle from date of diagnosis. PMB's covered in full in the network. If you choose any other provider, you are covered up to 80% of DHR
Neck and Back Operations: 
PMB's only
Joint Replacements: 
PMB's only
Prosthesis: 

PMB's only

Medical and Surgical Appliances: 
No benefit
Maternity Confinements: 
Subject to pre-authorisation. Unlimited at 100% of DHR
In Hospital Dentistry: 
No benefit
Take home Medicine: 
No benefit
Rehabilitation, Hospice and Step-down facilities: 
21 days of rehabilitation per person per annum. 3 days per approved admission per person for detoxification
Treatment for Mental Health: 
Covered in full at a network facility, or up to 80% of DHR at non-network facilities. Protocols apply. Up to 21 days for admissions or up to 15 out-of-hospital consultations pp
HIV / AIDS: 
Subject to registration on the HIV programme. Choose a KeyCare and Premier Plus HIV Network GP and Specialist to manage your condition to avoid a 20% co-payment
Ambulance Service: 
Netcare 911
International Travel Benefit: 
No benefit
Day-to-day benefits
GP consultations: 

No benefit

Specialist consultations: 

Up to R4 400 per person, per annum, if referred by a KeyCare Network GP

Acute medicine: 

No benefit

Over-the-counter (OTC) Medicine: 

No benefit

Optometry benefits: 
No benefit
Basic dentistry: 
No benefit
Specialised Dentistry: 
No benefit
Orthodontics: 

No benefit

MRI and CT Scans (Out of Hospital): 
Paid from Specialist Benefit up to R4 400 pppa
Radiology and Pathology: 
No benefit
Pregnancy benefits: 
8 antenatal consultations, 2 x 2D scans, including 1 x nuchal translucency test. A defined basket of blood tests. 5 x antenatal or postnatal classes or consultations with a registered nurse up until 2 years after giving birth
Physiotherapy and Occupational Therapy day to day: 
No benefit
Chronic Conditions
Provider: 
Chosen KeyCare GP or network pharmacy
Chronic Conditions: 

Diagnosis, treatment and care costs of 26 chronic conditions that fall under the PMB Chronic Disease List (CDL), issued by the Council for Medical Schemes. Subject to approval by the Chronic Illness Benefit

Additional Chronic Conditions: 
None
Preventative Care Benefits
Preventative Benefits: 

Screening tests for adults and children at a wellness network provider. Age specific tests for: pap smear, mammogram, prostate and HIV screening tests. Flu vaccine during pregnancy and for members > 65 years. Bowel cancer screening tests for members 45-75 years

Total Contributions
Total Contribution Main Member: 
1809.00
Total Contribution Adult: 
1809.00
Total Contribution Child*: 
410.00
Core R13 800 +
Risk Contributions
Risk Contribution Main Member: 
1809.00
Risk Contribution Adult: 
1809.00
Risk Contribution Child: 
410.00
Medical Aid Plan Name Term: 
KeyCare Core