Keyhealth Marketing Brochure 2012 Final

BENEFITS BROCHURE 2012
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 an accredited KeyHealth broker should you need assistance in choosing an option. Alternatively, call our Centurion sales office on 012 667 5100.
ESSENCE OPTION EQUILIBRIUM OPTION SILVER OPTION GOLD OPTION PLATINUM OPTION HEALTH BOOSTER
This is an entry level option providing hospital cover only. Hospitalisation is unlimited and covered at 100% of the agreed tariff. Hospitalisation is unlimited and covered at 100% of the agreed tariff. In-hospital, specialist services are covered up to 150% of MST. Out-of-hospital expenses are recoverable from a medical savings account and day-to-day benefits. This option provides unlimited hospital cover at 100% of the agreed tariff with adequate day-to-day benefits. It is suitable for younger families. This option provides unlimited hospital cover at 100% of the agreed tariff with a medical savings account and a generous day-to-day benefit. This option provides the most comprehensive cover. Hospitalisation is unlimited and covered at 100% of the agreed tariff.
(Included in all options) - This programme is aimed at preventative treatment. 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!
essence
HOSPITALISATION
CHRONIC HEALTH BOOSTER
HOSPITALISATION
equilibrium
SAVINGS DAY-TO-DAY CHRONIC
HEALTH BOOSTER
silver
HOSPITALISATION DAY-TO-DAY CHRONIC

HEALTH BOOSTER
HOSPITALISATION
gold
SAVINGS DAY-TO-DAY CHRONIC HEALTH BOOSTER
platinum
HOSPITALISATION DAY-TO-DAY CHRONIC HEALTH BOOSTER
KEYHEALTH options
04
KEYHEALTH MARKETING BROCHURE 2012
HEALTH BOOSTER
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 and cholesterol tests are available on the Health Booster programme.
05
TYPE
PREVENTIVE CARE*
Baby immunisation Flu vaccination Tetanus diphtheria injection Pneumococcal vaccination**
WHO & HOW OFTEN?
Child Dependants aged 6 as required by the Department of Health. Beneficiaries aged 18 once per year. Beneficiaries aged 60 once per year. High risk beneficiaries once per year. All Beneficiaries as and when required. Beneficiaries aged 60, and high risk as and when required
EARLY DETECTION TESTS*

Pap smear (Pathologist) Pap smear (consultation; GP or Gynaecologist) Mammogram General physical examination Female Beneficiaries aged 15 once per year. Female Beneficiaries aged 15 once per year. Female Beneficiaries aged 40 once every 2 years. Beneficiaries aged 30 and 59 once every 3 years. Beneficiaries aged >59 and 69 once every 2 years. Beneficiaries aged >69 once per year. 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. Beneficiaries aged 25 once per year. Beneficiaries all ages once per year. Beneficiaries aged 15 once every 5 years.
Prostate specific antigen (Pathologist)
Cholesterol test (Pathologist) Blood sugar test (Pathologist) HIV/AIDS test (Pathologist) Health Assessment (HA) Body mass index, Blood pressure measurement, Cholesterol Adult Beneficiaries once per year. test (finger prick), Blood sugar test (finger prick)
MATERNITY*
Antenatal visits (GP or Gynaecologist) & urine test (dipstick) Scans (one before the 24th week and one thereafter) Paediatrician visits
*Pre-authorisation essential to access benefits
Female Beneficiaries. Pre-notification of and pre-authorisation by the Scheme compulsory. Twelve (12) visits. Female Beneficiaries. Pre-notification of and pre-authorisation by the Scheme compulsory. Two (2) pregnancy scans. Baby registered on Scheme. Two (2) visits in babys 1st year.
**Only available on Platinum, Gold and Silver options
06
07
HOSPITALISATION
ESSENCE OPTION
TOTAL ANNUAL BENEFIT
HOSPITALISATION, THEATRE FEES, INTENSIVE & HIGH CARE UNIT
IN-HOSPITAL
MST ()
BENEFIT
EXPLANATORY NOTES / BENEFIT SUMMARY

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 Unlimited; up to 100% of Agreed Tariff. Unlimited; up to 100% of Agreed Tariff. Specialist and Anaesthetist services unlimited. Per admission. Pre-authorisation compulsory and subject to case management. Pfpa Pre-authorisation compulsory and subject to case management. PMB conditions only. Unlimited. Pre-authorisation compulsory. Pre-authorisation compulsory and subject to case management. PMB conditions in DSP hospitals only. Pre-authorisation compulsory and subject to case management. PMB conditions only. Pfpa. Pre-authorisation compulsory and subject to case management. 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. Unlimited Pre-authorisation compulsory and subject to case management, protocols and pricing. PMB conditions / trauma only.
Private Hospitals State hospitals Medicine on discharge PSYCHIATRIC TREATMENT SUB-ACUTE FACILITIES & WOUND CARE Wound care, hospice, private nursing, rehabilitation and step-down facilities. BLOOD TRANSFUSION ORGAN TRANSPLANT Hospitalisation, organ harvesting and drugs for immuno-suppressive therapy. DIALYSIS ONCOLOGY RADIOLOGY MRI and CT scans X-rays PET scans PATHOLOGY PROSTHETICS (Internal and External) 100% 100% 100% 100% R275 R12 000
100% 100%
100% 100% 100% R 10 000 R95 000
100% 100%
08
ESSENCE OPTION
OUT-OF-HOSPITAL
BENEFIT
Over-the-counter medication Over-the-counter reading glasses PATHOLOGY OPTICAL SERVICES Frames Lenses Eye test Contact lenses Refractive surgery DENTISTRY Conservative dentistry
MST ()
100%
BENEFIT
R445 R75

Pbpa Pbpa; one (1) pair per year. Subject to over-the-counter medication benefit. No benefit, except for PMB conditions. No benefit. No benefit. No benefit. No benefit. No benefit. Subject to DENIS protocols, Managed Care interventions and Scheme Rules. Exclusions apply in accordance with Scheme Rules.
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
100% 100% 100% 100% 100% 100%
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 and Scheme Rules. Exclusions apply in accordance with Scheme Rules.
Surgery in dental chair Surgery in-hospital (general anesthesia) Hospitalisation and Anesthetics
100% 100%
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.
Hospitalisation (general anesthesia)
100%
R1 000 co-payment per hospital admission. DENIS pre-authorisation compulsory. Removal of impacted wisdom teeth only. DENIS pre-authorisation not required.
Laughing gas in dental rooms IV conscious sedation in dental rooms
100% 100%
DENIS pre-authorisation compulsory. Limited to extensive dental treatment. PAY ALL DENTAL CO-PAYMENTS DIRECTLY TO THE SERVICE PROVIDER INVOLVED
09
CHRONIC MEDICATION AND OTHER BENEFIT-CATEGORIES

CHRONIC MEDICATION Category A (CDL) Category B (other) HIV/AIDS State hospitals AMBULANCE SERVICES MEDICAL APPLIANCES Wheelchairs, orthopedic appliances and incontinence equipment (including contraceptive devices). Hearing aids and maintenance ENDOSCOPIC PROCEDURES (SCOPES) Colonoscopy, Cystoscopy, Gastroscopy and Sigmoidoscopy. Hysteroscopy Arthroscopy, Laparoscopy (diagnostic) 100% Unlimited subject to reference pricing. Registration on Chronic Disease Programme compulsory. (30% co-payment applicable when not using a DSP pharmacy.) No benefit. Pfpa. Subject to registartion on HIV Programme (private hospitals, GP visits, medication and pathology) and case management. Unlimited. DSP - NETCARE 911 Unlimited (inter-hospital transfer subject to protocols). Pre-authorisation compulsory. Pfpa; combined in- and out-of-hospital benefit.
100%
R21 000
100% 100% R4 500
100%
No benefit. 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).
010
011
HOSPITALISATION
SAVINGS
DAY-TO-DAY
EQUILIBRIUM OPTION
IN-HOSPITAL
MST ()
BENEFIT

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 Unlimited; up to 100% of Agreed Tariff. Unlimited; up to 100% of Agreed Tariff. Specialist and Anaesthetist services unlimited. Per admission. 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. Pre-authorisation compulsory and subject to case management. PMB conditions only. Unlimited. Pre-authorisation compulsory. Pre-authorisation compulsory and subject to case management. PMB conditions in DSP hospitals only. Pre-authorisation compulsory and subject to case management. PMB conditions only. Pfpa. Pre-authorisation compulsory and subject to case management. 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. Unlimited Pre-authorisation compulsory and subject to case management, protocols and pricing. PMB conditions / trauma only.
Private Hospitals State hospitals Medicine on discharge PSYCHIATRIC TREATMENT 150% 100% 100% R335 R12 000 SUB-ACUTE FACILITIES & WOUND CARE Wound care, hospice, private nursing, rehabilitation and step-down facilities. BLOOD TRANSFUSION ORGAN TRANSPLANT Hospitalisation, organ harvesting and drugs for immuno-suppressive therapy. DIALYSIS ONCOLOGY RADIOLOGY 100%
100% 100%
100% 100% 100% R95 000
MRI and CT scans X-rays PET scans PATHOLOGY PROSTHETICS (Internal and External)
R10 000
100% 100%
012
EQUILIBRIUM OPTION
OUT-OF-HOSPITAL
BENEFIT
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. 100% 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. Over-the-counter reading glasses OPTICAL SERVICES Frames Lenses Eye test Contact lenses Refractive surgery PATHOLOGY DENTISTRY Conservative dentistry R75 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. Subject to MSA / day-to-day benefit. Subject to DENIS protocols, Managed Care interventions and Scheme Rules. Exclusions apply in accordance with Scheme Rules. 100% 100% 100% 100% 100% 100% 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. 100% 100% 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. 100% R1 000 co-payment per hospital admission. DENIS pre-authorisation compulsory. Removal of impacted wisdom teeth only. DENIS pre-authorisation not required. 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. Pbpa; one (1) pair per year. Subject to MSA / day-to-day benefit.
MST ()
BENEFIT
100%
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)
100% 100%
013

CHRONIC MEDICATION Category A (CDL) Category B (other) HIV/AIDS State hospitals AMBULANCE SERVICES MEDICAL APPLIANCES Wheelchairs, orthopedic appliances and incontinence equipment (including contraceptive devices). Hearing aids and maintenance ENDOSCOPIC PROCEDURES (SCOPES) Colonoscopy, Cystoscopy, Gastroscopy and Sigmoidoscopy. Hysteroscopy Arthroscopy, Laparoscopy (diagnostic) 100% Unlimited subject to reference pricing. Registration on Chronic Disease Programme compulsory. (30% co-payment applicable when not using a DSP pharmacy.) No benefit. Pfpa. Subject to registration on HIV Programme (private hospitals, GP visits, medication and pathology) and case management. Unlimited. DSP - NETCARE 911 Unlimited (inter-hospital transfer subject to protocols). Pre-authorisation compulsory. Pfpa; combined in- and out-of-hospital benefit.
100%
R21 000
100% 100% R4500
100%
No benefit. Subject to MSA. 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).
014
015
HOSPITALISATION
DAY-TO-DAY
SILVER OPTION
IN-HOSPITAL
MST ()
BENEFIT

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 Unlimited; up to 100% of Agreed Tariff. Unlimited; up to 100% of Agreed Tariff. Specialist and Anaesthetist services unlimited. Per admission. 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. Pre-authorisation compulsory and subject to case management. Pfpa; combined in- and out-of-hospital benefit. Pfpa sublimit. Unlimited. Pre-authorisation compulsory. Pre-authorisation compulsory and subject to case management. PMB conditions in DSP hospitals only. Pre-authorisation compulsory and subject to case management. PMB conditions only. Pfpa. Pre-authorisation compulsory and subject to case management. 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. Unlimited Pre-authorisation compulsory and subject to case management, protocols and pricing. PMB conditions / trauma only.
Private Hospitals State hospitals Medicine on discharge PSYCHIATRIC TREATMENT 100% 100% 100% R165 R12 000 SUB-ACUTE FACILITIES & WOUND CARE Hospice, private nursing, rehabilitation and step-down facilities. Wound Care BLOOD TRANSFUSION ORGAN TRANSPLANT Hospitalisation, organ harvesting and drugs for immuno-suppressive therapy. DIALYSIS ONCOLOGY RADIOLOGY MRI and CT scans X-rays PET scans PATHOLOGY PROSTHETICS (Internal and External) 100% R18 000 R5 800 100% 100%
100% 100% 100% R10 000 R106 000
100% 100%
016
SILVER OPTION
OUT-OF-HOSPITAL
BENEFIT
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. 100% 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. Over-the-counter medicine Over-the-counter reading glasses OPTICAL SERVICES Frames Lenses Eye test Contact lenses Refractive surgery PATHOLOGY 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 Maxillo-Facial and Oral surgery 100% 100% 100% 100% 100% 100% 100% R420 60% 100% R980 R85 R950 R320 Pfpa sublimit. Subject to day-to-day benefit. Pbpa; one (1) pair per year. Subject to over-the-counter medicine sublimit. 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 optical benefit. One (1) test pbp2a. Subject to overall optical benefit. Pbpa. Subject to overall optical benefit. No benefit. Subject to day-to-day benefit. (Co-payment payable directly to the service provider involved.) Subject to DENIS protocols, Managed Care interventions and Scheme Rules. Exclusions apply in accordance with Scheme Rules. Two (2) check-ups pbpa.
MST ()
BENEFIT
100%
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.
Surgery in dental chair
100%
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.
Surgery in-hospital (general anesthesia) Hospitalisation and Anesthetics Hospitalisation (general anesthesia)
100%
100% 100%
R1 000 co-payment per hospital admission. DENIS pre-authorisation compulsory. Removal of impacted wisdom teeth only. DENIS pre-authorisation not required.
Laughing gas in dental rooms 100% IV conscious sedation in dental rooms
017

CHRONIC MEDICATION Category A (CDL) Category B (other) HIV/AIDS State hospitals AMBULANCE SERVICES MEDICAL APPLIANCES Wheelchairs, orthopedic appliances, hearing aids and incontinence equipment (including contraceptive devices and maintenance of hearing aids). ENDOSCOPIC PROCEDURES (SCOPES) Colonoscopy, Cystoscopy, Gastroscopy and Sigmoidoscopy. Hysteroscopy Arthroscopy, Laparoscopy (diagnostic) 100% Unlimited subject to reference pricing. Registration on Chronic Disease Programme compulsory. (30% co-payment applicable when not using a DSP pharmacy.) No benefit. Pfpa. Subject to registration on HIV Programme (private hospitals, GP visits, medication and pathology) and case management. Unlimited. DSP - NETCARE 911 Unlimited (inter-hospital transfer subject to protocols). Pre-authorisation compulsory. Pfpa; combined in- and out-of-hospital benefit. Hearing aids subject to case management and protocols.
100%
R23 500
100% 100% R4 500
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).
018
019
HOSPITALISATION
SAVINGS
DAY-TO-DAY
GOLD OPTION
HOSPITALISATION, THEATRE FEES, INTENSIVE & HIGH CARE UNIT Private Hospitals State hospitals Medicine on discharge PSYCHIATRIC TREATMENT 100% 100% 100% R335 R24 500 SUB-ACUTE FACILITIES & WOUND CARE Hospice, private nursing, rehabilitation and step-down facilities. Wound care BLOOD TRANSFUSION ORGAN TRANSPLANT Hospitalisation, organ harvesting and drugs for immuno-suppressive therapy. DIALYSIS ONCOLOGY RADIOLOGY 100% R24 500 R8 000 100% 100% 100% 100% 100% R220 000
IN-HOSPITAL
MST ()
BENEFIT

Pre-authorisation compulsory. Unlimited; up to 100% of Agreed Tariff. Unlimited; up to 100% of Agreed Tariff. Specialist and Anaesthetist services unlimited. Per admission. Pre-authorisation compulsory and subject to case management. Pfpa. Combined benefit; in- and out-of-hospital. Sublimit of R10 000 pfpa on out-of-hospital psychiatric treatment. Pre-authorisation compulsory and subject to case management. Pfpa; combined in- and out-of-hospital benefit. Pfpa sublimit. Unlimited. Pre-authorisation compulsory. Pre-authorisation compulsory and subject to case management. PMB conditions in DSP hospitals only. Pre-authorisation compulsory and subject to case management. PMB conditions only. Pfpa. Pre-authorisation compulsory and subject to case management. 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. Unlimited Pfpa, combined benefit. Pre-authorisation compulsory and subject to case management, protocols and pricing.
R10 000
100% 100%
R22 500
020
GOLD OPTION
OUT-OF-HOSPITAL
BENEFIT
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. 100% 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. Over-the-counter medicine Over-the-counter reading glasses OPTICAL SERVICES Frames Lenses Eye test Contact lenses Refractive surgery PATHOLOGY 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 80% 80% 100% 100% 100% 100% 100% 100% 100% 100% R1 200 R105 R1 900 R600 Pfpa sublimit. Subject to MSA / day-to-day benefit. Pbpa; one (1) pair per year. Subject to the over-the-counter medicine sublimit. 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 optical benefit. 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. Subject to MSA / day-to-day benefit. (Co-payment payable directly to the service provider involved.) 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.
MST ()
BENEFIT
100%
R900 60%
80%
Periodontics
80%
021
OUT-OF-HOSPITAL
BENEFIT
[DENTISTRY Continued] Maxillo-Facial and Oral surgery Surgery in dental chair
MST ()
BENEFIT
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.
100%
R1 000 co-payment per hospital admission. DENIS pre-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
100% 100%

CHRONIC MEDICATION Category A (CDL) 100% Unlimited subject to reference pricing. Registration on Chronic Disease Programme compulsory. (15% co-payment applicable when using a non-DSP pharmacy.) No benefit. Pfpa. Subject to registration on HIV Programme (private hospitals, GP visits, medication and pathology) and case management. Unlimited. DSP - NETCARE 911 Unlimited (inter-hospital transfer subject to protocols). Pre-authorisation compulsory. Pfpa; combined in- and out-of-hospital benefit.
Category B (other) HIV/AIDS State hospitals AMBULANCE SERVICES MEDICAL APPLIANCES Wheelchairs, orthopedic appliances and incontinence equipment (including contraceptive devices). HEARING AIDS Hearing aids Maintenance (batteries included) ENDOSCOPIC PROCEDURES (SCOPES) Colonoscopy, Cystoscopy, Gastroscopy and Sigmoidoscopy. Hysteroscopy Arthroscopy, Laparoscopy (diagnostic)
100%
R29 000
100% 100% R5 500
100% R5 800 R600 100%
No authorisation required. Pfp4a. Pbpa. 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).
022
023
HOSPITALISATION
DAY-TO-DAY
PLATINUM OPTION
HOSPITALISATION, THEATRE FEES, INTENSIVE & HIGH CARE UNIT Private Hospitals State hospitals Medicine on discharge PSYCHIATRIC TREATMENT 100% 100% 100% R385 R36 000 SUB-ACUTE FACILITIES & WOUND CARE Hospice, private nursing, rehabilitation and step-down facilities. Wound care BLOOD TRANSFUSION ORGAN TRANSPLANT Hospitalisation, organ harvesting and drugs for immuno-suppressive therapy. DIALYSIS ONCOLOGY RADIOLOGY 100% R30 000 R10 500 100% 100%
IN-HOSPITAL
MST ()
BENEFIT

Pre-authorisation compulsory. Unlimited; up to 100% of Agreed Tariff. Unlimited; up to 100% of Agreed Tariff. Specialist and Anaesthetist services unlimited. Per admission. Pre-authorisation compulsory and subject to case management. Pfpa. Combined in- and out-of-hospital. Sublimit of R15 000 pfpa on out-of-hospital psychiatric treatment. Pre-authorisation compulsory and subject to case management. Pfpa; combined in- and out-of-hospital benefit. Pfpa sublimit. Unlimited. Pre-authorisation compulsory. Unlimited. Pre-authorisation compulsory and subject to case management. Unlimited. Pre-authorisation compulsory and subject to case management. Unlimited. Pre-authorisation compulsory and subject to case management. 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.)
100% 100% 100%
R15 000
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. Unlimited Pfpa, combined benefit. Pre-authorisation compulsory and subject to case management, protocols and pricing. 20% co-payment when limit is exceeded.
100% 100% 80%
R55 000
024
PLATINUM OPTION
OUT-OF-HOSPITAL
BENEFIT
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. 100% 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 R1 800 R125 R3 200 R950 Pfpa sublimit. Subject to day-to-day and threshold. Pbpa; one (1) pair per year. Subject to the over-the-counter medicine sublimit. 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. Pfpa sublimit. Subject to day-to-day benefit and threshold. Pfpa sublimit. Subject to day-to-day benefit and threshold. (Co-payment payable directly to the service provider involved.) Subject to DENIS protocols, Managed Care interventions and Scheme Rules. Exclusions apply in accordance with Scheme Rules. 100% 100% 100% 100% 100% 100% 100% 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. 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 Perio Programme.
MST ()
BENEFIT
90% 90% Over-the-counter medicine Over-the-counter reading glasses OPTICAL SERVICES Frames Lenses Eye test Contact lenses Refractive surgery PHYSIOTHERAPY PATHOLOGY 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 80% 80% 80% 80% R2 700 100%
100%
100% 80%
R1 500 R6 400 R8 500 R8 500
Periodontics
80%
025
OUT-OF-HOSPITAL
BENEFIT
[DENTISTRY Continued] Maxillo-Facial and Oral surgery Surgery in dental chair
MST ()
BENEFIT
Subject to DENIS protocols, Managed Care interventions and Scheme Rules. Exclusions apply in accordance with Scheme Rules. 100% 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. 100% R1 000 co-payment per hospital admission. Extensive dental treatment for very young Child Dependants. Removal of impacted wisdom teeth. DENIS pre-authorisation compulsory.
100%
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 100% 100%

CHRONIC MEDICATION Category A (CDL) 100% Unlimited subject to reference pricing. Registration on Chronic Disease Programme compulsory. (10% co-payment applicable when using a non-DSP pharmacy.) R11 500 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.) Pfpa. Subject to registration on HIV Programme (private hospitals, GP visits, medication and pathology) and case management. Unlimited. DSP - NETCARE 911 Unlimited (inter-hospital transfer subject to protocols). Pre-authorisation compulsory. R7 000 Pfpa; combined in- and out-of-hospital benefit.
Category B (other)
90%
HIV/AIDS State hospitals AMBULANCE SERVICES MEDICAL APPLIANCES Wheelchairs, orthopedic appliances and incontinence equipment (including contraceptive devices). HEARING AIDS Hearing aids Maintenance (batteries included) ENDOSCOPIC PROCEDURES (SCOPES) Colonoscopy, Cystoscopy, Gastroscopy and Sigmoidoscopy. Hysteroscopy Arthroscopy, Laparoscopy (diagnostic)
100%
R35 000
100% 100%
100% R11 500 R800 100%
No authorisation required. Pfp4a. Pbpa. 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).
026
2012 MONTHLY CONTRIBUTIONS

ESSENCE
Principal Member
Monthly contribution R899
Adult Dependant
R543
Child Dependant
R275
EQUILIBRIUM
Principal Member
Monthly contribution Monthly savings Total monthly contribution R1 070 R 93 R1 163
Adult Dependant
R645 R56 R701
Child Dependant
R327 R28 R355
SILVER
Principal Member
Monthly contribution R1 937
Adult Dependant
R1 041
Child Dependant
R402
GOLD
Principal Member
Monthly contribution Monthly savings Total monthly contribution R2 326 R258 R2 584
Adult Dependant
R1 571 R174 R1 745
Child Dependant
R455 R50 R505
PLATINUM
Principal Member
Monthly contribution R4 061
Adult Dependant
R2 846
Child Dependant
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 benefits will be payable in respect of the following (for a complete list of the Scheme exclusions, please visit the Schemes website at www.keyhealthmedical.co.za.): Examinations, consultations, treatment, operations and procedures relating to: Acupuncture Biokinetics Biostress assessments Colonic irrigations Cosmetic procedures DNA testing EBCT Electronic Beam Computed Tomography (coronary and heart) Gastroplasty IQ tests and learning problems Laser-assisted functional reconstruction of palate and uvula, including follow-up procedures Obesity Reversals of sterilisations Reversals of vasectomies Sclerotherapy of varicose veins Certain charges and purchases (e.g. humidifiers and blood pressure monitors), as referred to in the Scheme Rules, may also be excluded.
027
PRESCRIBED MINIMUM BENEFITS (PMBs)

WHAT ARE PMBs?
In terms of the Medical Schemes Act, Act 131 of 1998, medical schemes must provide minimum hospital-based benefits for certain conditions. These hospital benefits are available even during a waiting and/or exclusion period. These prescribed minimum benefits cover members for specific treatments and services, available in a State hospital. A list of the conditions covered in-hospital is available on the website of the Council for Medical Schemes, at www.medicalschemes.com. PMBs are defined by the Medical Schemes Act with the aim of ensuring that all medical scheme members have access to certain minimum health benefits, regardless of the Scheme benefit option they have selected, their age or the state of their health. In terms of the Act, medical schemes have to cover the costs related 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 includes 25 chronic conditions as defined in the Chronic Disease List. The treating Doctor decides whether a condition is a PMB or not by taking into account the symptoms only a diagnosis-based approach.
TABLE 1(CATEGORY A): PRESCRIBED MINIMUM BENEFIT CHRONIC DISEASE LIST (CDL) (ALL OPTIONS) 1. 2. 3. 4. 5. 6. 7. 8. 9. 10. 11. 12. 13. 14. 15. 16. 17. 18. 19. 20. 21. 22. 23. 24. 25. 26. Addison's disease Asthma Bipolar mood disorder Bronchiectasis Cardiac failure Cardiomyopathy disease Chronic renal disease Coronary artery disease Crohn's disease Chronic obstructive pulmonary disorder Diabetes insipidus Diabetes mellitus type 1 Dysrhythmias Epilepsy Glaucoma Haemophilia Hyperlipidaemia Hypertension Hypothyroidism Hormone replacement therapy (HRT)# Multiple sclerosis Parkinson's disease Rheumatoid arthritis Schizophrenia Systemic lupus erythematosis Ulcerative colitis TABLE 2 (CATEGORY B): OTHER CHRONIC CONDITIONS (PLATINUM OPTION ONLY) 1. 2. 3. 4. 5. 6. 7. 8. 9. 10. 11. 12. 13. 14. 15. 16. 17. 18. 19. 20. 21. 22. 23. 24. 25. 26. 27. 28. 29. Acne Allergic rhinitis Alzheimer's disease Ankylosing spondylitis Benign prostatic hypertrophy Clotting disorders* Cystic fibrosis Deep vein thrombosis* Diverticulitis and irritable bowel syndrome Gastro-esophageal reflux disease Hypoparathyroidism* Hyperkinesis (Attention deficit disorder) Hyperthyroidism Interstitial fibrosis Iron deficiency anemia Major depression* Meniere's disease Menopausal disorder (calcium only)* Migraine Myasthenia gravis Osteoarthritis Osteoporosis Paraplegia, quadriplegia* Peripheral vascular disease* Psoriasis Rheumatic fever Stroke* Testosterone deficiency Urinary incontinence
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 number of diverse conditions, broadly divided into 15 categories. The Scheme makes use of formularies for chronic medication to manage costs and ensure accessibility to appropriate care for all Members. A formulary is an approved list of medication applicable to the chronic conditions covered by the Scheme. These formularies do not in any way compromise the quality of healthcare that a Member will receive.
DSPs for PMBs
Any services falling within the prescribed minimum benefits rendered by the Schemes DSPs will be covered in full. The Scheme 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 fall within 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 pay 100% of MST in respect of any services for prescribed minimum benefits which are voluntarily obtained by a Beneficiary from a service provider, other than the DSP . Subject to application and approval, any services in respect of PMBs, which are involuntarily obtained by the Beneficiary from a service provider other than the DSP will be covered in full. ,
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 / pharmacy Table 2 - A 10% co-payment not applicable to PMB conditions. Please refer to www.keyhealthmedical.co.za for any possible changes to this list.
028
HOW TO?
OBTAIN AUTHORISATION FOR HOSPITALISATION
Before admission to hospital, it is a requirement that Beneficiaries phone 0860 671 060 (Authorisation Call Centre) for authorisation. The following information must be provided when 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 relevant ICD-10 or CPT4 code(s); 5. Date of admission and the date on which the procedure(s) is/are scheduled to be carried out; and 6. Particulars of the Doctor or service provider (practice number, initials, surname and telephone 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 be payable. Please note that a Beneficiary needs to obtain authorisation within 24 hours prior to an admission, or within two (2) working days after an emergency admission (a family member, friend or the hospital can call on the Beneficiarys behalf if he/she is unable to do so), otherwise no benefits will be paid. entries on their claims statements to ensure that the services were indeed rendered. By doing this, Members will notice any inaccurate claims against their benefits. If there appears to be a problem, Members must contact the service provider and enquire about the claims submitted on their behalf. If any services charged for were not rendered, alert the Scheme. In this way, Members will help ensure that the Scheme pays only for the services received. If the Scheme has a members e-mail address on its system, an electronic notification will be sent each time a claim is processed. This will further help Members to manage their medical expenses.
USE THE E-MAIL FACILITY

Webmail is a simple e-mail-based interface for Members to gain access to their Medical Scheme information without having to phone the Client Service Centre. A Member can activate webmail by e-mailing the Scheme at webmail@keyhealthmedical.co.za. No details are required in the subject field or the body of the mail. The e-mail address of the Member will be authenticated against the e-mail address loaded on the system. If an e-mail address has not been loaded onto the system, or if there is more than one Member using the same e-mail address, the Member will receive a response informing him/her that KeyHealth is unable to authenticate the e-mail address and is therefore unable to generate the webmail. Once an e-mail address has been authenticated, the system will respond by e-mailing the Member a complete package of information. This package includes: Membership details Case history Claims history Benefits Contributions Claims advice
REGISTER CHRONIC ILLNESS CONDITIONS

Authorisation for chronic medication is subject to the following: The treating Doctor or the Pharmacist must register chronic conditions with MediKredit on 0800 132 345 as detailed clinical information, including the conditions ICD-10 code and severity status, is required. The Doctor will then issue a prescription to obtain the medication from a local pharmacy, a Scheme DSP pharmacy or the Doctors dispensary. Certain products will only be authorised if prescribed by an appropriate Specialist. These Specialists must contact MediKredit on 0800 132 345 for further information.
USE THE SMS FACILITY

Members may gain access to useful information 24 hours a day by sending an SMS to 32899. The options are as follows: Send an SMS with the letter B in the message field to receive an SMS with current benefits available. Send an SMS with the letter C in the message field to receive an e-mail with claims, as per last statement. Send an SMS with the letter D in the message field to receive an SMS with membership details. Send an SMS with the letters IC and the relevant ICD-10 code in the message field to receive an SMS with 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.
CLAIM FROM THE SCHEME

The Scheme strives to make the claims procedure as userfriendly as possible. In most cases, claims are submitted on Members behalf by the service provider (Doctor, Dentist, Physiotherapist, Pharmacist, etc.). The Scheme must emphasise, however, that Members should check all the claim
029
GLOSSARY
Agreed tariff Chronic Disease List (CDL) Day-to-day benefit A tariff agreed to from time to time between the Scheme and service providers, e.g. hospital groups. A list of chronic illness conditions that is covered in terms of legislation. A combined out-of-hospital limit which may be used by any beneficiary in respect of General Practitioners, Specialists, radiology, optical, pathology, prescribed medicine and auxiliary services and which may include a sub-limit for self-medication. A service provider contracted by the Scheme to manage dental benefits on behalf of the Scheme according to protocols. A provider that renders healthcare services to members at an agreed tariff and has to be used to qualify for certain benefits. 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. An additional benefit for preventative health care. Also referred to as KeyHealth tariff. A set of tariffs the Scheme pays for services rendered by service providers. A cost and quality optical management programme provided by Opticlear. 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. Over-The-Counter (medicine or glasses) Medical Savings Account per beneficiary per annum (per year) per beneficiary biennially [every two (second) year(s)] per family per annum (per year) per family biennially [every two (second) year(s)] two (2) per family per annum (per year) DENIS (Dental Information Systems) Designated Service Provider (DSP) Emergency
Health Booster Medical Scheme Tariff (MST) Optical Management Physical Trauma
OTC MSA pbpa pbp2a pfpa pfp2a 2pfpa
030
NOTES
* 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
www.keyhealthmedical.co.za
CONTACT US
Client Service Centre e-mail Netcare 911 Hospital pre-authorisation e-mail Oncology management programme e-mail DENIS (dental) pre-authorisation e-mail DENIS ( dental) claims enquiries / Submissions e-mail Lifesense disease management Crisis line ( Netcare 911) Chronic medication registration (to be used by providers) Optical management 0860 67 1050 info@keyhealthmedical.co.za 082 911 0860 67 1060 Preauth@keyhealthmedical.co.za 0860 67 1060 oncology@keyhealthmedical.co.za 0860 10 4926 keyhealthenq@denis.co.za Fax : 0866 770 336 Fax : 012 679 4469 Fax: 0860 111 390 Fax: 012 679 4471
claims@denis.co.za 0860 50 6080 082 911
0800 13 2345 0861 67 8427 Fax : 0861 100 397
Fraud line e-mail New Business e-mail Membership e-mail Broker queries (Client Service Centre) e-mail Website
0860 11 0820 fraud@keyhealthmedical.co.za 012 667 5100 newbusiness@keyhealthmedical.co.za 0860 67 1050 membership@keyhealthmedical.co.za billing@keyhealthmedical.co.za 0860 67 1050 brokersupport@keyhealthmedical.co.za www.keyhealthmedical.co.za P Box 14145 .O. Lyttelton 0140
Fax: 0866 050 656
Fax : 0860 111 390
Postal address:

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BENEFITS BROCHURE 2012

CHRONIC HEALTH BOOSTER

HOSPITALISATION DAY-TO-DAY CHRONIC

HOSPITALISATION DAY-TO-DAY CHRONIC HEALTH BOOSTER