Keyhealth Platinum medical aid plan: 2017

Out-of-hospital, scheme pays for some: specialised radiology (co-payment), dentistry, medicine, optometry, maternity, medical appliances, sub-acute facilities, preventative benefits. Limits apply. All else paid from fund, from above threshold benefit 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: R6,796 R4,764 R1,433
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, sub-acute facilities, preventative benefits. Limits apply. All else paid from fund, from above threshold benefit or from out of pocket, unless PMB.
Main: Adult: Child:
(S) Savings: R0- R0- R0-
Extended Fund: R9,115 R8,840 R2,160
(SP) Self Payment: R3,190 R2,840 R1,045
Threshold (S+SP): R12,305 R11,680 R3,205
Above Threshold: No limit No limit No limit

Compare with these plans:
Hospital Choice:
  • Unlimited
Specialised Radiology:
  • MRI and CT scans: R20,800 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: R41,600 per family in and out of hospital
  • Wound care sublimit: R14,500

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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: R6,796 R4,764 R1,433
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, sub-acute facilities, preventative benefits. Limits apply. All else paid from fund, from above threshold benefit or from out of pocket, unless PMB.
Main: Adult: Child:
(S) Savings: R0- R0- R0-
Extended Fund: R9,115 R8,840 R2,160
(SP) Self Payment: R3,190 R2,840 R1,045
Threshold (S+SP): R12,305 R11,680 R3,205
Above Threshold: No limit No limit No limit

Compare with these plans:

Specialists consultations:
  • Paid from day-to-day benefit
Pathology:
  • Limited to R11,900 per family, with a 20% co-payment
  • Paid from day-to-day benefit
General radiology:
  • Paid from day-to-day benefit
Specialised radiology:
  • MRI and CT scans: R20,800 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)
  • Physiotherapy limited to R11,900 per family. Otherwise unlimited.
  • Paid from day-to-day benefit

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MATERNITY BENEFITS:
Hospital stay:
Overall Annual Limit (OAL):
Unlimited overall, with sub-limits
Contributions:
Main: Adult: Child:
Total Cost: R6,796 R4,764 R1,433
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, sub-acute facilities, preventative benefits. Limits apply. All else paid from fund, from above threshold benefit or from out of pocket, unless PMB.
Main: Adult: Child:
(S) Savings: R0- R0- R0-
Extended Fund: R9,115 R8,840 R2,160
(SP) Self Payment: R3,190 R2,840 R1,045
Threshold (S+SP): R12,305 R11,680 R3,205
Above Threshold: No limit No limit No limit

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):
  • Unlimited, 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: R6,796 R4,764 R1,433
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, sub-acute facilities, preventative benefits. Limits apply. All else paid from fund, from above threshold benefit or from out of pocket, unless PMB.
Main: Adult: Child:
(S) Savings: R0- R0- R0-
Extended Fund: R9,115 R8,840 R2,160
(SP) Self Payment: R3,190 R2,840 R1,045
Threshold (S+SP): R12,305 R11,680 R3,205
Above Threshold: No limit No limit No limit

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 implants (R3,700 limit) 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: R6,796 R4,764 R1,433
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, sub-acute facilities, preventative benefits. Limits apply. All else paid from fund, from above threshold benefit or from out of pocket, unless PMB.
Main: Adult: Child:
(S) Savings: R0- R0- R0-
Extended Fund: R9,115 R8,840 R2,160
(SP) Self Payment: R3,190 R2,840 R1,045
Threshold (S+SP): R12,305 R11,680 R3,205
Above Threshold: No limit No limit No limit

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
  • non-PMBs chronic: R16,000 per person, and R32,600 per family with 10% co-payment. Paid by scheme.
Overall Annual Limit (OAL):
Unlimited overall, with sub-limits
Contributions:
Main: Adult: Child:
Total Cost: R6,796 R4,764 R1,433
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, sub-acute facilities, preventative benefits. Limits apply. All else paid from fund, from above threshold benefit or from out of pocket, unless PMB.
Main: Adult: Child:
(S) Savings: R0- R0- R0-
Extended Fund: R9,115 R8,840 R2,160
(SP) Self Payment: R3,190 R2,840 R1,045
Threshold (S+SP): R12,305 R11,680 R3,205
Above Threshold: No limit No limit No limit

Compare with these plans:
Acute (presrcibed) medication:
  • Paid from day-to-day benefit
MainAdultChild
R7,520R3,410R1,670
Over-the-counter:
  • Limited to R2,560 per family
  • Paid from day-to-day benefit
Birth Control:
On Discharge:
  • R450
Notes:
  • Chronic medicine: 10% co-payment where non-DSP pharmacy is used
  • Reference pricing

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OPTOMETRY:
Optometry:
  • Limited to R4,400 per person every 2 years
  • sub limits: Frames (R1,315), Lenses (one pair), Contact lenses (R2,050)
  • Paid from day-to-day benefit
  • In addition, one pair of reading glasses (R175 limit) from the over-the-counter medicine benefit
  • Refractive surgery: R8,850 per person every two years
Overall Annual Limit (OAL):
Unlimited overall, with sub-limits
Contributions:
Main: Adult: Child:
Total Cost: R6,796 R4,764 R1,433
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, sub-acute facilities, preventative benefits. Limits apply. All else paid from fund, from above threshold benefit or from out of pocket, unless PMB.
Main: Adult: Child:
(S) Savings: R0- R0- R0-
Extended Fund: R9,115 R8,840 R2,160
(SP) Self Payment: R3,190 R2,840 R1,045
Threshold (S+SP): R12,305 R11,680 R3,205
Above Threshold: No limit No limit No limit

Compare with these plans:

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MENTAL HEALTH:
In-hospital:
  • Psychiatric: R47,000 per family in and out of hospital, with sub limit of R19,600 for out-of hospital
Overall Annual Limit (OAL):
Unlimited overall, with sub-limits
Contributions:
Main: Adult: Child:
Total Cost: R6,796 R4,764 R1,433
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, sub-acute facilities, preventative benefits. Limits apply. All else paid from fund, from above threshold benefit or from out of pocket, unless PMB.
Main: Adult: Child:
(S) Savings: R0- R0- R0-
Extended Fund: R9,115 R8,840 R2,160
(SP) Self Payment: R3,190 R2,840 R1,045
Threshold (S+SP): R12,305 R11,680 R3,205
Above Threshold: No limit No limit No limit

Compare with these plans:


Out-of-hospital:
  • Psychiatric: R47,000 per family in and out of hospital, with sub limit of R19,600 for out-of hospital

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OTHER BENEFITS:
General Appliances:
  • R9,700 per family, in and out of hospital
Overall Annual Limit (OAL):
Unlimited overall, with sub-limits
Contributions:
Main: Adult: Child:
Total Cost: R6,796 R4,764 R1,433
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, sub-acute facilities, preventative benefits. Limits apply. All else paid from fund, from above threshold benefit or from out of pocket, unless PMB.
Main: Adult: Child:
(S) Savings: R0- R0- R0-
Extended Fund: R9,115 R8,840 R2,160
(SP) Self Payment: R3,190 R2,840 R1,045
Threshold (S+SP): R12,305 R11,680 R3,205
Above Threshold: No limit No limit No limit

Compare with these plans:

1.1. Hearing Aids:
  • See "General Appliances" limit
1.2. Wheelchairs:
  • R29,300 per family, every 4 years/li>
  • R1,115 for maintenance
Dialysis:
  • Unlimited
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: R6,796 R4,764 R1,433
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, sub-acute facilities, preventative benefits. Limits apply. All else paid from fund, from above threshold benefit or from out of pocket, unless PMB.
Main: Adult: Child:
(S) Savings: R0- R0- R0-
Extended Fund: R9,115 R8,840 R2,160
(SP) Self Payment: R3,190 R2,840 R1,045
Threshold (S+SP): R12,305 R11,680 R3,205
Above Threshold: No limit No limit No limit

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: R6,796 R4,764 R1,433
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, sub-acute facilities, preventative benefits. Limits apply. All else paid from fund, from above threshold benefit or from out of pocket, unless PMB.
Main: Adult: Child:
(S) Savings: R0- R0- R0-
Extended Fund: R9,115 R8,840 R2,160
(SP) Self Payment: R3,190 R2,840 R1,045
Threshold (S+SP): R12,305 R11,680 R3,205
Above Threshold: No limit No limit No limit

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