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KEYHEALTH PLATINUM 2019

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Type of Medical Aid Plan: 
Threshold
Medical Aid Year: 
2019
Day to day Benefits: 

Routine medical expenses like, General practitioner and specialist consultations, radiology (incl. Nucleur Medicine Study and bone density scans). Prescribed and over-the-counter medicine. Optical and auxiliary services, e.g. physiotherapy, occupational therapy, contraceptive pills and biokinetics. This is a family benefit which means that one member of the family can use the total benefit allocation.

PM -R10 180 pa

AD - R9875 pa

CD - R2415 pa

 

(When the routine benefits have been depleted, Member will enter the
Self-funding gap.

In Hospital Benefits
Hospital Rate of Payment: 
100% of Scheme Rate
Hospitals: 

Private hospitals. Unlimited, up to 100% of Agreed Tariff, subject to use of DSP hospital (Netcare or Life Healthcare).

(30% co-payment at non-DSP hospital.)

Upfront Payments to hospitals: 

R1 560 co-payment per scan (in- or out of hospital).

Hospital Dentistry R1 560 per admission.

Casualty / Emergency Visits: 
Easy ER available no upfront payment required.
Specialists: 
Unlimited, subject to use of DSP provider.
Other healthcare professionals eg. Physio, Occupational, Dietician: 
100% of Scheme Rate
Radiology and pathology: 
Pre-authorisation: 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.)
Scopes (gastroscopy, colonoscopy, sigmoidoscopy and proctoscopy): 
100% of Scheme Rate
MRI and CT scans: 
R23 200 P.A Pfpa. R1 560 co-payment per scan (in- or out-of-hospital), excluding confirmed PMBs.
Dialysis: 
Unlimited. Pre-authorisation compulsory and subject to Case Management and Scheme Protocols.
Organ Transplants: 
Unlimited, subject to use of DSP Provider. Pre-authorisation compulsory and subject to Case Management.
Oncology / Cancer: 
Unlimited. Pre-authorisation compulsory and subject to case management and Scheme Protocols.
Neck and Back Operations: 
Unlimited, up to 100% of Agreed Tariff.
Joint Replacements: 
Unlimited, up to 100% of Agreed Tariff.
Prosthesis: 

Unlimited. Pre-authorisation compulsory and subject to Case Management,

reference pricing, DSP and Scheme Protocols.

Medical and Surgical Appliances: 
R10 850 Pfpa. Combined in- and out-of-hospital benefit, subject to quantities and protocols. No pre-authorisation required.
Maternity Confinements: 
Private ward for 3 days for natural birth.
In Hospital Dentistry: 
Hospital Dentistry R1 560 per admission.
Take home Medicine: 
R500 Per admission.
Rehabilitation, Hospice and Step-down facilities: 
R46 500 Pre-authorisation compulsory and subject to Case Management and Scheme Protocols. Pfpa. Wound care is included in this benefit, up to an amount of R16 200. Combined in- and out-of-hospital benefit.
Treatment for Mental Health: 
R52 500 Pre-authorisation compulsory. Pfpa. Combined benefit; in- and out-of-hospital. Out-of-hospital treatment is limited to R21 900.
HIV / AIDS: 
Unlimited. Chronic Disease Programme, managed by Lifesense, applicable.
Ambulance Service: 
DSP – NETCARE 911. Unlimited, subject to use of DSP and protocols. (20% co-payment at non-DSP service provider.)
International Travel Benefit: 
No benefit
Day-to-day benefits
GP consultations: 

Routine medical expenses like, General practitioner and specialist consultations, radiology (incl. Nucleur Medicine Study and bone density scans). Prescribed and over-the-counter medicine. Optical and auxiliary services, e.g. physiotherapy, occupational therapy, contraceptive pills and biokinetics. This is a family benefit which means that one member of the family can use the total benefit allocation.

PM -R10 180 pa

AD - R9875 pa

CD - R2415 pa

(When the routine benefits have been depleted, Member will enter the
Self-funding gap

Specialist consultations: 

Routine medical expenses like, General practitioner and specialist consultations, radiology (incl. Nucleur Medicine Study and bone density scans). Prescribed and over-the-counter medicine. Optical and auxiliary services, e.g. physiotherapy, occupational therapy, contraceptive pills and biokinetics. This is a family benefit which means that one member of the family can use the total benefit allocation.

PM -R10 180 pa

AD - R9875 pa

CD - R2415 pa

(When the routine benefits have been depleted, Member will enter the
Self-funding ga

Acute medicine: 

Subject to day-to-day and Threshold Zone sublimits apply

PM: R10 180 p.a.
AD: R9 875 p.a.
CD: R2 415 p.a.
(When the routine benefits have been depleted, Member will enter the
Self-funding gap.

Over-the-counter (OTC) Medicine: 

R2 860 Per family per year sublimit. Subject to day-to-day and Threshold Zone.

Over-the-counter reading glasses. R195. Per beneficiary per annum (per year). 1 pair per year. Subject to the over-the-counter medicine sublimit.

Optometry benefits: 
100% Total optical benefit: R4 900 per beneficiary biennially. Subject to day-to-day benefit, Threshold Zone and Optical Management. Benefit confirmation compulsory.
Basic dentistry: 
subject to DENIS protocols, Managed Care interventions and Scheme Rules. Exclusions apply in accordance with Scheme Rules. 100% Consultations, X-rays: Intra & Extra-oral, Oral hygiene, Fillings, Tooth extractions, Root canal treatment & Plastic dentures
Specialised Dentistry: 
DENIS (Dental Information Systems) protocols and Scheme Rules apply. Exclusions apply in accordance with Scheme Rules
Orthodontics: 

Orthodontics 80%.

DENIS (Dental Information Systems) pre-authorisation compulsory.

Cases will be clinically assessed using orthodontic indices where function is impaired.

Not for cosmetic reasons; laboratory costs also excluded.

Only 1 beneficiary per family may commence treatment per calendar year.

Limited to Beneficiaries between 9 and 18 years.

Periodontics 80%.

DENIS pre-authorisation compulsory.

Limited to conservative, non-surgical therapy (root planing) only and will be applied to beneficiaries registered on the Perio Programme.

MRI and CT Scans (Out of Hospital): 
R23 200 Per family per year. R1 560 co-payment per scan (in- or out-of-hospital), excluding confirmed PMBs
Radiology and Pathology: 
Pathology R13 300 pfpa
Pregnancy benefits: 
12 Antenatal visits, 2 Ultrasounds (GP, Gynaecologist or midwife), urine test. Pre-notification of and pre-authorisation by the Scheme compulsory. Short payments/co-payments for services & birthing fees. 2 Paediatrician visits. Ante-natal vitamins & class
Chronic Conditions
Provider: 
Designated Service Provider
Chronic Conditions: 

Category A (CDL) 100% & Unlimited – subject to reference pricing, protocols and registration on Chronic Disease Programme.

(10% co-payment at non-DSP pharmacy.)

Preventative Care Benefits
Preventative Benefits: 

PREVENTIVE CARE

Baby immunisation. Child dependants aged ≤6 – as required by the Department of Health.

Flu vaccination. All beneficiaries.

Tetanus diphtheria injection. All beneficiaries – as and when required.

Pneumococcal vaccination. All beneficiaries.

Malaria medication. All beneficiaries – R340 once per year.

HPV vaccination. Female beneficiaries aged ≤9-14 – 2 doses per lifetime.

EARLY DETECTION TESTS

Pap smear (Pathologist). Female beneficiaries aged ≥15 – once per year.

Pap smear (including consultation and pelvic organs ultrasound; GP or Gynaecologist). Female beneficiaries aged ≥15– once per year.

Mammogram. Female beneficiaries aged ≥40 – once per year.

Prostate specific antigen (PSA) (Pathologist). Male beneficiaries aged ≥40 – once per year.

HIV/AIDS test (Pathologist). Beneficiaries aged ≥15 – once per year.

Health Assessment (HA): Body mass index, Blood pressure measurement, Cholesterol test (finger prick), Blood sugar test (finger prick) PSA (finger prick). Adult beneficiaries – once per year.

Total Contributions
Total Contribution Main Member: 
8112.00
Total Contribution Adult: 
5687.00
Total Contribution Child*: 
1711.00
PLATINUM OPTION
Annual Medical Savings Account
Annual Medical Savings Main Member: 
10180.00
Annual Medical Savings Adult: 
9875.00
Annual Medical Savings Child*: 
2415.00
Risk Contributions
Risk Contribution Main Member: 
8112.00
Risk Contribution Adult: 
5687.00
Risk Contribution Child: 
1711.00
Medical Aid Plan Name Term: 
Any