Keyhealth Marketing Brochure 2012 Final

7/31/2019 Keyhealth Marketing Brochure 2012 Final

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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.


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.


PMB conditions in DSP hospitals only.

DIALYSIS 100% Pre-authorisation compulsory and subject to case management.


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()


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.)


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.



Limited to extensive dental treatment.

PAY ALL DENTAL CO-PAYMENTS DIRECTLY TO THE SERVICE PROVIDER INVOLVED


ESSENCE OPTION


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EQUILIBRIUM OPTIONIN-HOSPITAL

TOTAL ANNUAL BENEFIT

MST()


HOSPITALISATION, THEATRE FEES, INTENSIVE &

HIGH CARE UNIT






Facet joint injections - R1 000

Functional nasal surgery - R2 000


Rhizotomy - R2 500




Private Hospitals

State hospitals






R12 000


Pfpa. Combined benefit; in- and out-of-hospital. Sublimit of

R5 000 pfpa on out-of-hospital psychiatric treatment.


Wound care, hospice, private nursing,

rehabilitation and step-down facilities.




ORGAN TRANSPLANT








management.

RADIOLOGY

MRI and CT scans

X-rays

PET scans

100%

R10 000


MRI and CT scans. Hospitalisation not covered if radiology is for

investigative purposes only. (MSA / day-to-day benefits will then

apply.)



Unlimited.

No benefit.

PATHOLOGY 100% UnlimitedPROSTHETICS

(Internal and External)



HOSPITALISATION

SAVINGS

DAY-TO-DAY

CHRONIC

HEALTH BOOSTER



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MST()


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%

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:


Adult Dependant: R890 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


Consultations

X-rays: Intra-oral

X-rays: Extra-oral

Oral hygiene

Fillings

Tooth extractions

Root canal treatment

Plastic and metal frame dentures









100%

100%

100%

100%

100%

100%

100%

100%

100%

100%

100%



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.



No benefit. Subject to MSA.





Rules.


Wisdom teeth removal only.



Scheme Rules. Exclusions apply in accordance with Scheme Rules.









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


Pfpa; combined in- and out-of-hospital benefit.


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).





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IN-HOSPITALTOTAL ANNUAL BENEFIT

MST()



HIGH CARE UNIT






Facet joint injections - R1 000

Functional nasal surgery - R2 000


Rhizotomy - R2 500




Private Hospitals

State hospitals






R12 000


Pfpa. Combined benefit; in- and out-of-hospital. Sublimit of

R5 000 pfpa on out-of-hospital psychiatric treatment.


Hospice, private nursing, rehabilitation and

step-down facilities.

Wound Care

100%

R18 000

R5 800



Pfpa sublimit.


ORGAN TRANSPLANTHospitalisation, organ harvesting and drugs for


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.


management.

RADIOLOGY

MRI and CT scans

X-rays

PET scans

100%

R10 000


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




SILVER OPTION

HOSPITALISATION

DAY-TO-DAY

CHRONIC

HEALTH BOOSTER



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MST()


DAY-TO-DAY BENEFIT





Over-the-counter medicine


100%

100% R980

R85

Limited to:


Adult Dependant: R3 390 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









100%

100%

100%

100%

100%

100%

100%

100%

100%

100%

100%

100%



Two (2) check-ups pbpa.

One (1) pbp3a.

Two (2) scale and polish treatments pbpa.



One (1) set (an upper and a lower jaw) pbp4a.

No benefit




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.




R1 000 co-payment per hospital admission.DENIS pre-authorisation compulsory.




Limited to extensive dental treatment.PAY ALL DENTAL CO-PAYMENTS DIRECTLY TO THE SERVICE PROVIDER INVOLVED


SILVER OPTION


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CHRONIC MEDICATION AND OTHER BENEFIT-CATEGORIESCHRONIC MEDICATION

Category A (CDL)

Category B (other)



(30% co-payment applicable when not using a DSP pharmacy.)

No benefit.

HIV/AIDS

State hospitals



Unlimited.



MEDICAL APPLIANCES

Wheelchairs, orthopedic appliances, hearing

aids and incontinence equipment (including

contraceptive devices and maintenance of

hearing aids).

100%

R4 500



Hearing aids subject to case management and protocols.



Sigmoidoscopy.

Hysteroscopy



scopes.






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HOSPITALISATION

SAVINGS

DAY-TO-DAY

CHRONIC

HEALTH BOOSTER


MST()



HIGH CARE UNIT


Private Hospitals

State hospitals






R24 500


Pfpa. Combined benefit; in- and out-of-hospital. Sublimit ofR10 000 pfpa on out-of-hospital psychiatric treatment.




Wound care

100%

R24 500

R8 000



Pfpa sublimit.


ORGAN TRANSPLANT








management.

RADIOLOGY

MRI and CT scans

X-rays

PET scans

100%

R10 000


MRI, CT and PET scans. Hospitalisation not covered if radiology is for

investigative purposes only. (MSA / day-to-day benefits will then apply.)



Unlimited.

Unlimited number of scans. Limited to R11 000 per scan.

PATHOLOGY 100% Unlimited

PROSTHETICS


100% R22 500 Pfpa, combined benefit. Pre-authorisation compulsory and

subject to case management, protocols and pricing.

GOLD OPTION



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MST()


DAY-TO-DAY BENEFIT







100%

100% R1 200

R105

Annual Medical Savings Account (MSA):




Additional benefits limited to:




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.


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


Consultations

X-rays: Intra-oral

X-rays: Extra-oral

Oral hygiene

Fillings


Plastic dentures


Partial metal frame dentures

Crowns and bridges

Implants

Orthodontics

Periodontics

100%

100%

100%

100%

100%

100%

100%

80%

80%

80%

80%




One (1) pbp3a. (Additional benefit may be granted where

specialised dental treatment planning / follow-up is required.)







One (1) partial metal frame (an upper or a lower jaw) pbp5a.


A treatment plan and X-rays may be requested.

One (1) per tooth pbp5a.



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.


GOLD OPTION


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CategoryA(CDL)

CategoryB (other)



(15% co-payment applicable when using a non-DSP pharmacy.)

No benefit.

HIV/AIDS

State hospitals



Unlimited.



MEDICAL APPLIANCES

Wheelchairs, orthopedic appliances and

incontinence equipment

(including contraceptive devices).

100%

R5 500



HEARING AIDS

Hearing aids

Maintenance (batteries included)

100%

R5 800

R600

No authorisation required.

Pfp4a.

Pbpa.



Sigmoidoscopy.

Hysteroscopy


100% Pre-authorisation compulsory. No co-payment on out-of-hospitalscopes.






MST()


[DENTISTRYContinued]








100%

100%

100%

100%

100%





intervention/treatment. Claims for oral pathology procedures






R1 000 co-payment per hospital admission. DENISpre-authorisation compulsory.

Extensive dental treatment for very young Child Dependants.

Removal of impacted wisdom teeth.






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PLATINUM OPTION

HOSPITALISATION

DAY-TO-DAY

CHRONIC

HEALTH BOOSTER



MST()



HIGH CARE UNIT


Private Hospitals

State hospitals






R36 000


Pfpa. Combined in- and out-of-hospital. Sublimit ofR15 000 pfpa on out-of-hospital psychiatric treatment.




Wound care

100%

R30 000

R10 500



Pfpa sublimit.


ORGAN TRANSPLANT



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


MRI, CT and PET scans. Hospitalisation not covered if radiology is

for investigative purposes only. (Day-to-day benefits will then apply.)



Unlimited.

Unlimited number of scans. Limited to R11 000 per scan.

PATHOLOGY 100% Unlimited

PROSTHETICS


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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PLATINUM OPTION


MST()


DAY-TO-DAY BENEFIT







100%

90%

90%

100% R1 800

R125

Limited to:



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.


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


Consultations

X-rays: Intra-oral

X-rays: Extra-oral

Oral hygiene

Fillings


Plastic dentures


Partial metal frame dentures

Crowns and bridges

Implants

Orthodontics

Periodontics

100%

100%

100%

100%

100%

100%

100%

80%

80%

80%

80%

80%

R2 700




One (1) pbp3a. (Additional benefit may be granted where

specialised dental treatment planning / follow-up is required.)





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.


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.


Limited to conservative, non-surgical therapy (root planing)

only and will be applied to Beneficiaries registered on the PerioProgramme.


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CategoryA(CDL)

CategoryB (other)

100%

90% R11 500

Unlimited subject to reference pricing.


(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



Unlimited.



MEDICAL APPLIANCES

Wheelchairs, orthopedic appliances and

incontinence equipment

(including contraceptive devices).

100%

R7 000



HEARING AIDS

Hearing aids

Maintenance (batteries included)

100%

R11 500

R800

No authorisation required.

Pfp4a.

Pbpa.



Sigmoidoscopy.

Hysteroscopy



scopes.





MST()


[DENTISTRYContinued]








100%

100%

100%

100%

100%





intervention/treatment. Claims for oral pathology procedures







Extensive dental treatment for very young Child Dependants.

Removal of impacted wisdom teeth.







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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 savings R258 R174 R50

Total monthly contribution R2 584 R1 745 R505

PLATINUMPrincipal Member Adult Dependant Child Dependant


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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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


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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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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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.

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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


New Business 012 667 5100

e-mail [email protected] Fax: 0866 050 656

Membership 0860 67 1050

[email protected]

[email protected] : 0860 111 390

Broker queries (Client Service Centre) 0860 67 1050


Website www.keyhealthmedical.co.za

Postal address:

P.O. Box 14145

Lyttelton

0140

CONTACT US

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Keyhealth Marketing Brochure 2012 Final