Keyhealth Gold medical aid plan: 2017

Out-of-hospital, scheme pays for some: specialised radiology (co-payment), dentistry, medicine, optometry, maternity, medical appliances, hearing aids, preventative benefits. Limits apply. All else paid from savings, from fund or from out of pocket, unless PMB. Pay for all children.

View all plans in this scheme

IN HOSPITAL PROCEDURES:
Payout Rate for Specialists:
Overall Annual Limit (OAL):
Unlimited overall, with sub-limits
Contributions:
Main: Adult: Child:
Total Cost: R4,143 R2,802 R812
Children: Pay for all children
Day-to-Day Benefit:
Out-of-hospital, scheme pays for some: specialised radiology (co-payment), dentistry, medicine, optometry, maternity, medical appliances, hearing aids, preventative benefits. Limits apply. All else paid from savings, from fund or from out of pocket, unless PMB.
Main: Adult: Child:
(S) Savings: R4,968 R3,360 R972
Extended Fund: R4,190 R3,120 R1,000

Compare with these plans:
Hospital Choice:
  • Unlimited
Specialised Radiology:
  • MRI and CT scans: R13,900 per family with R1,400 co-payment, in and out of hospital
  • PET scans: R30,800 per person. Maximum R15,400 per scan
Supplementary Services: (Physio, etc)
Transplants:
  • Unlimited, subject to use of DSP
Co-payments:
  • Specialised radiology: R1,400 co-payment
Alternatives to hospitals:
  • Hospice, private nursing, rehab, step-down and wound care: R34,100 per family in and out of hospital
  • Wound care sublimit: R11,200

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OUT OF HOSPITAL BENEFITS:
GP consultations:
  • Paid from day-to-day benefit
Overall Annual Limit (OAL):
Unlimited overall, with sub-limits
Contributions:
Main: Adult: Child:
Total Cost: R4,143 R2,802 R812
Children: Pay for all children
Day-to-Day Benefit:
Out-of-hospital, scheme pays for some: specialised radiology (co-payment), dentistry, medicine, optometry, maternity, medical appliances, hearing aids, preventative benefits. Limits apply. All else paid from savings, from fund or from out of pocket, unless PMB.
Main: Adult: Child:
(S) Savings: R4,968 R3,360 R972
Extended Fund: R4,190 R3,120 R1,000

Compare with these plans:

Specialists consultations:
  • Paid from day-to-day benefit
Pathology:
  • 30% co-payment
  • Paid from day-to-day benefit
General radiology:
  • Paid from day-to-day benefit
Specialised radiology:
  • MRI and CT scans: R13,900 per family with R1,400 co-payment, in and out of hospital
  • PET scans: R30,800 per person. Maximum R15,400 per scan
Supplementary Services: (Physio, etc)
  • Paid from day-to-day benefit

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MATERNITY BENEFITS:
Hospital stay:
  • Private ward for 3 days for natural birth
Overall Annual Limit (OAL):
Unlimited overall, with sub-limits
Contributions:
Main: Adult: Child:
Total Cost: R4,143 R2,802 R812
Children: Pay for all children
Day-to-Day Benefit:
Out-of-hospital, scheme pays for some: specialised radiology (co-payment), dentistry, medicine, optometry, maternity, medical appliances, hearing aids, preventative benefits. Limits apply. All else paid from savings, from fund or from out of pocket, unless PMB.
Main: Adult: Child:
(S) Savings: R4,968 R3,360 R972
Extended Fund: R4,190 R3,120 R1,000

Compare with these plans:

Consultations:
  • 12 consults, paid by scheme
  • Vitamins: R1,690 per pregnancy
  • Antenatal classes: R1,690 for first pregnancies
Scans:
  • 2 x 2D scans, paid by scheme

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CANCER (ONCOLOGY):
Overall coverage (in and out of hospital):
  • R337,500 per family, subject to use of DSP and scheme protocols

Note: All oncology benefits are assessed on a case-by-case basis, and are subject to protocols, preferred providers and scheme rules. Benefit covers out-of-hospital treatment too, like chemotherapy.
Overall Annual Limit (OAL):
Unlimited overall, with sub-limits
Contributions:
Main: Adult: Child:
Total Cost: R4,143 R2,802 R812
Children: Pay for all children
Day-to-Day Benefit:
Out-of-hospital, scheme pays for some: specialised radiology (co-payment), dentistry, medicine, optometry, maternity, medical appliances, hearing aids, preventative benefits. Limits apply. All else paid from savings, from fund or from out of pocket, unless PMB.
Main: Adult: Child:
(S) Savings: R4,968 R3,360 R972
Extended Fund: R4,190 R3,120 R1,000

Compare with these plans:

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DENTISTRY:
Dentistry:
  • Standard dentistry: paid by scheme. Includes plastic dentures
  • Specialised dentistry: 80% scheme tariff, includes metal frame dentures, crowns and bridges, and periodontics
  • Hospitalisation: R1,400 co-payment. For young children and removal of wisdom teeth.
Overall Annual Limit (OAL):
Unlimited overall, with sub-limits
Contributions:
Main: Adult: Child:
Total Cost: R4,143 R2,802 R812
Children: Pay for all children
Day-to-Day Benefit:
Out-of-hospital, scheme pays for some: specialised radiology (co-payment), dentistry, medicine, optometry, maternity, medical appliances, hearing aids, preventative benefits. Limits apply. All else paid from savings, from fund or from out of pocket, unless PMB.
Main: Adult: Child:
(S) Savings: R4,968 R3,360 R972
Extended Fund: R4,190 R3,120 R1,000

Compare with these plans:

Orthodontics:
  • 80% scheme tariff
    • , where function is impaired. 9-18yrs.
Maxillo Facial Surgery:
  • Subject to protocols

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MEDICATION:
Chronic:
  • PMBs chronic: paid by scheme
Overall Annual Limit (OAL):
Unlimited overall, with sub-limits
Contributions:
Main: Adult: Child:
Total Cost: R4,143 R2,802 R812
Children: Pay for all children
Day-to-Day Benefit:
Out-of-hospital, scheme pays for some: specialised radiology (co-payment), dentistry, medicine, optometry, maternity, medical appliances, hearing aids, preventative benefits. Limits apply. All else paid from savings, from fund or from out of pocket, unless PMB.
Main: Adult: Child:
(S) Savings: R4,968 R3,360 R972
Extended Fund: R4,190 R3,120 R1,000

Compare with these plans:
Acute (presrcibed) medication:
  • Paid from day-to-day benefit
Over-the-counter:
  • Limited to R1,710 per family
  • Paid from day-to-day benefit
Birth Control:
On Discharge:
  • R450
Notes:
  • Chronic medicine: 15% co-payment where non-DSP pharmacy is used
  • Reference pricing

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OPTOMETRY:
Optometry:
  • Limited to R2,630 per person every 2 years
  • sub limits: Frames (R830), Lenses (one pair), Contact lenses (R1,250)
  • Paid from day-to-day benefit
  • In addition, one pair of reading glasses (R150 limit) from the over-the-counter medicine benefit
Overall Annual Limit (OAL):
Unlimited overall, with sub-limits
Contributions:
Main: Adult: Child:
Total Cost: R4,143 R2,802 R812
Children: Pay for all children
Day-to-Day Benefit:
Out-of-hospital, scheme pays for some: specialised radiology (co-payment), dentistry, medicine, optometry, maternity, medical appliances, hearing aids, preventative benefits. Limits apply. All else paid from savings, from fund or from out of pocket, unless PMB.
Main: Adult: Child:
(S) Savings: R4,968 R3,360 R972
Extended Fund: R4,190 R3,120 R1,000

Compare with these plans:

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MENTAL HEALTH:
In-hospital:
  • Psychiatric: R34,100 per family in and out of hospital, with sub limit of R13,900 for out-of hospital
Overall Annual Limit (OAL):
Unlimited overall, with sub-limits
Contributions:
Main: Adult: Child:
Total Cost: R4,143 R2,802 R812
Children: Pay for all children
Day-to-Day Benefit:
Out-of-hospital, scheme pays for some: specialised radiology (co-payment), dentistry, medicine, optometry, maternity, medical appliances, hearing aids, preventative benefits. Limits apply. All else paid from savings, from fund or from out of pocket, unless PMB.
Main: Adult: Child:
(S) Savings: R4,968 R3,360 R972
Extended Fund: R4,190 R3,120 R1,000

Compare with these plans:


Out-of-hospital:
  • Psychiatric: R34,100 per family in and out of hospital, with sub limit of R13,900 for out-of hospital

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OTHER BENEFITS:
General Appliances:
  • R7,600 per family, in and out of hospital
Overall Annual Limit (OAL):
Unlimited overall, with sub-limits
Contributions:
Main: Adult: Child:
Total Cost: R4,143 R2,802 R812
Children: Pay for all children
Day-to-Day Benefit:
Out-of-hospital, scheme pays for some: specialised radiology (co-payment), dentistry, medicine, optometry, maternity, medical appliances, hearing aids, preventative benefits. Limits apply. All else paid from savings, from fund or from out of pocket, unless PMB.
Main: Adult: Child:
(S) Savings: R4,968 R3,360 R972
Extended Fund: R4,190 R3,120 R1,000

Compare with these plans:

1.1. Hearing Aids:
  • See "General Appliances" limit
1.2. Wheelchairs:
  • R13,500 per family, every 4 years/li>
  • R840 for maintenance
Dialysis:
  • PMB only
HIV:
  • Unlimited
  • Since HIV is a PMB certain out-of-hospital benefits are automatically covered by all schemes according to protocols
Emergency Transport: Netcare911
International Coverage:
Other:

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WELLNESS/PREVENTATIVE BENEFITS:
Flu vaccination:
  • Covered
Overall Annual Limit (OAL):
Unlimited overall, with sub-limits
Contributions:
Main: Adult: Child:
Total Cost: R4,143 R2,802 R812
Children: Pay for all children
Day-to-Day Benefit:
Out-of-hospital, scheme pays for some: specialised radiology (co-payment), dentistry, medicine, optometry, maternity, medical appliances, hearing aids, preventative benefits. Limits apply. All else paid from savings, from fund or from out of pocket, unless PMB.
Main: Adult: Child:
(S) Savings: R4,968 R3,360 R972
Extended Fund: R4,190 R3,120 R1,000

Compare with these plans:

Pneumonia vaccines:
  • Covered
Back Rehabilitation Programme:
Biometric Screening:
  • Covered
Child Immunisation:
  • Covered
Pap Smear:
  • Covered, 15yrs+
Mammogram:
  • Covered, 40yrs+ every two years
PAS Test:
  • Covered, 40yrs+
HIV Test:
  • Covered
    • , 15yrs+

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PROSTHESIS:
Overal Limit:
Overall Annual Limit (OAL):
Unlimited overall, with sub-limits
Contributions:
Main: Adult: Child:
Total Cost: R4,143 R2,802 R812
Children: Pay for all children
Day-to-Day Benefit:
Out-of-hospital, scheme pays for some: specialised radiology (co-payment), dentistry, medicine, optometry, maternity, medical appliances, hearing aids, preventative benefits. Limits apply. All else paid from savings, from fund or from out of pocket, unless PMB.
Main: Adult: Child:
(S) Savings: R4,968 R3,360 R972
Extended Fund: R4,190 R3,120 R1,000

Compare with these plans:
Sub-limits:

    Important!
  • Unless specified, assume that all benefits are paid are paid at 100% scheme rate
  • No limits or co-payments can apply to treatment of PMBs, which is always unlimited, although subject to strict protocols and scheme rules.
  • “Unlimited” benefits are still subject to authorisation, protocols and sublimits
  • Assume that all benefits need to be pre-authorised