The KeyCare Series
KeyCare offers you the best, most affordable cover through the KeyCare network of hospitals and doctors.
You can choose KeyCare Plus, KeyCare Access or KeyCare Core:
- Unlimited hospital cover in our KeyCare network of hospitals
- Guaranteed full cover in hospital for specialists on the KeyCare network, and up to 100% of the Discovery Health Rate for other healthcare professionals
- Essential cover for chronic medicine on the KeyCare medicine list for all CDL chronic conditions
- Unlimited cover for medically appropriate GP consultations, blood tests, x-rays or medicine in our KeyCare network on the KeyCare Plus and KeyCare Access Plans
What is your hospital cover?
There is no overall limit on your hospital cover.
You have cover for:
- medical emergencies – you can go to any private hospital
- planned admissions – On KeyCare Core and KeyCare Plus you must go to a hospital in the KeyCare network
- KeyCare Access covers you in our network of private hospitals for emergencies, trauma, and childbirth and care for your baby up to 12 months after childbirth, and at our contracted network of state facilities for all other hospital care.
Your hospital cover is made up of:
- the account from the hospital
- all accounts – like accounts from your admitting doctor, anaesthetist or any approved healthcare expenses. We call these related accounts.
Remember:Limits and rules apply to some healthcare services and procedures in hospital.
What is a medical emergency?
A medical emergency is the sudden and, at the time, unexpected onset of a health condition that needs immediate medical or surgical treatment. If you do not get this treatment serious impairment to bodily functions or dysfunction of a bodily organ or part, or your life would be placed in serious jeopardy.
How you are covered for emergencies:
In an emergency, go straight to hospital. If you need medically equipped transport, call 0860 999 911. This line is managed by highly qualified emergency personnel who will send air or road emergency evacuation transport to you, depending on which is most appropriate. You must let us know about your admission as soon as possible.
Are you covered for HIV medicines in an emergency?
Yes. We cover you if you need HIV medicine to prevent HIV infection through mother-to-child transmission, occupational and traumatic exposure to HIV or sexual assault.
Call us immediately on 0860 99 88 77 - treatment must start as soon as possible.
How do we pay your hospital account?
On KeyCare Core and KeyCare Plus, we cover you in any hospital in the KeyCare network of hospitals. If you don’t go to a KeyCare network hospital for planned admission, you would have to pay the claims yourself.
On KeyCare Access, healthcare services for approved admissions for emergencies, trauma, childbirth and care for your baby up to 12 months after childbirth are covered in our KeyCare Access network of private hospitals with no overall limit. We pay approved admissions for all other hospital care in our contracted network of state facilities.
What are related accounts?
Related accounts are your doctor or treating healthcare professional’s accounts and they are separate from the hospital account.
How do we pay related accounts?
The accounts from your doctor or treating healthcare professional are separate from the hospital account. We call these related accounts. A related account can be an account from the admitting doctor or anaesthetist, or for any approved healthcare services you receive while you’re in hospital, like X-rays or blood tests.
- We cover these accounts up to 100% of the Discovery Health Rate.
If you are charged more than the Discovery Health Rate, you will have to pay for the rest of the amount.
What procedures are covered at the KeyCare day surgery network? (KeyCare Core and KeyCare Plus)
You have access to full cover for certain procedures done at our day surgery network.
The procedures covered are:
|Arthrocentesis (joint injection)||Hysteroscopy||Simple abdominal hernia repair|
|Cataract surgery||Myringotomy||Simple nasal procedure for nose bleeding (that is, nasal plugging and nasal cautery)|
|Cautery of vulva warts||Myringotomy with intubation (grommets)||Tonsillectomy|
|Circumcision||Treatment of Bartholin’s cyst/abscess|
|Diagnostic D&C||Removal of pins and plates|
On KeyCare Access we cover these procedures in our network of contracted state facilities and in the KeyCare Access Hospital Network if related to emergencies, trauma, childbirth or care for your baby in the KeyCare Access.
How do you find a hospital in the KeyCare Hospital Network?
View the list of the hospitals and the day surgery facilities on the KeyCare network.
- You are covered in full at any of the hospitals in the KeyCare Network and our day surgery network
- You don’t have to pay an amount before you are admitted for a planned procedure
What must you do before you go to hospital for a planned procedure?
- On KeyCare Core, see your GP
- On KeyCare Plus and KeyCare Access Plans, you must see your chosen GP in the KeyCare GP network
- Choose the admitting doctor, who will decide if it is necessary for you to be admitted to hospital
- If the doctor is a specialist, you need approval from us before seeing the specialist
- Check if your specialist has an agreement with us
- Choose the hospital where you want to be admitted
- To get full cover, you must choose one of the hospitals in KeyCare network for planned admissions
- Find out how we cover other healthcare professionals, like your anaesthetist, by calling us on 0860 99 88 77 for confirmation
- Call us on 0860 99 88 77 to confirm your hospital admission at least 48 hours before you go in.
Is your cover subject to certain rules?
There may be some expenses while you are in hospital that we don’t cover, for example private ward costs. Certain procedures, medicines or new technologies need separate approval while you are in hospital. Talk about this with your doctor or the hospital.
Find out more about our clinical rules, guidelines and policies for cover in Do We Cover?
Your cover for healthcare professionals
For approved admissions on KeyCare Plus and KeyCare Core and for emergencies, trauma, childbirth and care for your baby up to 12 months on KeyCare Access.
You must use a healthcare professional in our network. We have agreements with these doctors and pay them in full. These healthcare professionals are also designated providers for Prescribed Minimum Benefits.
Use MaPS Advisor to search for a specialist and other healthcare professionals who we have an agreement with.
By using specialists in our network, you won’t be faced with any gaps or co-payments when it comes to claiming.
Will you have a co-payment if you use other specialists?
If you are treated by a specialist who we do not have an agreement with, we cover you up to 100% of the Discovery Health Rate.Remember:
You may have a upfront payment if your specialist charges above these rates.
What about other healthcare professionals?
- We cover GPs, radiology, pathology and other healthcare services up to 100% of the Discovery Health Rate.
- If the healthcare professional charges more than the Discovery Health Rate, you must pay the rest.
- Use MaPS Advisor to search for other healthcare professionals who we have an agreement with.
By using healthcare professionals who we have an agreement with, you won’t be faced with any gaps or co-payments when it comes to claiming.
How do we cover investigations?
KeyCare Plus and KeyCare Core
Please phone us before going for a scope to confirm where the scope can be done. We will cover your scope in our network of day-case facilities up to 100% of the Discovery Health Rate.
On KeyCare Access we cover these procedures in our network of contracted state facilities and in the KeyCare Access Hospital Network if related to emergencies, trauma, childbirth or care for your baby in the KeyCare Access
Your cover for MRI and CT scans in hospital
MRI and CT scans are like x-rays but show much more detail. They are used when an x-ray doesn’t show enough.
- If your scan is related to an approved hospital stay, we pay it from your Hospital Benefit.
- If it is not, we pay for it from your Specialist Benefit, up to R2 750 for each person We don’t pay for MRI or CT scans that are related to conservative back or neck treatment. This is treatment for your back or neck that is not surgery.
Do you have cover for dental treatment in hospital?
No. We don’t cover in hospital dentistry on the KeyCare plans.
Which healthcare services are unlimited?
These in-hospital healthcare services have no overall limit:
- Allied healthcare professionals, like physiotherapists
- Pathology and radiology
Remember: There are limits and rules that apply to some healthcare services and procedures.
Which healthcare services have an annual limit?
These are the only services that have a limit in hospital:
|KeyCare Core and KeyCare Plus||KeyCare Access|
|Mental health||21 days for each person||21 days for each person covered in our contracted network of state facilities|
|Alcohol and drug rehabilitation||21 days for each person||21 days for each person covered in our contracted network of state facilities|
|Cataract surgery||We cover cataract surgery as long as we have approved your treatment at a doctor and facility in our network for cataract surgery.||Covered in our contracted network of state facilities|
|Chronic dialysis||We cover these expenses in full as long as we have approved your treatment at a doctor and facility in our network||We cover these expenses in full as long as we have approved your treatment at a doctor and facility in our network|
|Compassionate care||R28 500 for each person in their lifetime|
What does your Chronic Illness Benefit cover?
You get cover for a comprehensive list of chronic conditions, HIV and AIDS and cancer. You have cover for a list of 27 conditions on our Chronic Disease List, as long as your chronic medicine is on the KeyCare medicine list.
- KeyCare Plus and KeyCare Access: your chosen GP must prescribe your approved chronic medicine
- KeyCare Core: any GP can prescribe your approved chronic medicine
You need to get your approved chronic medicine from one of our network pharmacies or from your chosen KeyCare GP – if he or she dispenses medicine.
- If you get your medicine anywhere else, you would have to pay 20% of the Discovery Health Rate for medicines.
- If you choose chronic medicine that is not on your medicine list, you must pay for it yourself.
What do you have to do to get chronic illness benefits?
We need to approve your application before we cover your condition. To apply, you can download and complete the Chronic Illness Benefit Application. Fill in the application form with your doctor’s help and send it to us. We will send you a letter detailing the cover available to you.
We pay medicine up to the maximum of the Discovery Health Rate for medicines.
What is the Discovery Health Rate for medicines?
This is the price of the medicine as well as a fee for dispensing it. Discovery Health has negotiated contracts with over 2 000 pharmacies, who have agreed to charge no more than this rate. If you use a pharmacy outside of this network, you will have to pay part of the dispensing fee charged by the pharmacy.
Use our online MaPS Advisor to find a network pharmacy in your area that we have an agreement with.
Are you covered for cancer treatment?
We cover cancer treatment if it qualifies as a Prescribed Minimum Benefit and you are treated by a cancer specialist in our network.
Are you covered for HIV and AIDS?
HIV and AIDS can be a sensitive matter, and our HIV healthcare team respects your right to privacy. You can be assured of confidentiality and sensitivity at all times.
- You have access to clinically sound and cost-effective treatment
- We use the Prescribed Minimum Benefit guidelines when approving HIV-related services
- For members registered on the HIVCare Programme there is no overall limit on hospital cover
- However, cover for all costs for HIV and AIDS-related hospital admissions is not automatic. When you know you’re going to hospital, you need to preauthorise your admission at least 48 hours before you go in
- You can also apply to preauthorise your admission here.
Please speak to a Discovery Health consultant by calling 0860 99 88 77 to discuss this programme.
Find out more about the HIVCare Programme
Do the Prescribed Minimum Benefits apply to my cover?
The Prescribed Minimum Benefits are guided by a set list of medical conditions that are defined in the Medical Schemes Act of 1998. All medical schemes in South Africa must include the Prescribed Minimum Benefits in the health plans they offer to their members. There are, however, certain requirements that must be met before members can benefit from the Prescribed Minimum Benefits.
The medical condition must be part of the list of defined conditions for Prescribed Minimum Benefits.
You may have to send Discovery Health the results of your medical tests and investigations that confirm the diagnosis of your medical condition.
This will allow the Scheme to identify your condition as one that qualifies for treatment.
The treating doctor has to provide the relevant documentation to assist Discovery Health in confirming the diagnosis.
The treatment needed must match the treatments included in the defined benefits.
There are standard treatments, procedures, investigations and consultations for each condition.
You must use the Scheme’s nominated healthcare professional.
You must use a doctor, specialist or other healthcare professional Discovery Health has an agreement with. There are some cases where it is not necessary to meet these requirements, but you will still have cover. An example of this is in a life-threatening emergency.
When do the Prescribed Minimum Benefits not apply?
There are some circumstances where you will not have cover under the Prescribed Minimum Benefits. This can happen when a person joins the medical scheme for the first time, with no prior medical scheme membership. It can also happen if someone joins a medical scheme more than 90 days after leaving his or her previous medical scheme.
How do your day-to-day benefits work?
Members on the KeyCare Plus and KeyCare Access Plans have cover for the following day-to-day medical expenses:
- GP visits: you must choose a GP from the KeyCare GP network, you must go to this GP for us to cover your consultations and some minor procedures
- Basic x-Rays: we pay for a list of basic x-rays at a network provider. Your chosen GP must ask for the x-rays to be done
- Blood, urine and other fluid and tissue tests: we pay for a list of these tests, your chosen GP must ask for these tests by filling in a Discovery Health pathology form
- Medicines to treat conditions that don’t last long: we pay for medicines from our medicine list if they are prescribed or dispensed by your chosen GP
- One out-of-network GP visit: if you need to see a doctor and your chosen GP is not available, each person on your plan can go to any GP once
- Basic dentistry: we cover consultations, fillings and tooth removal at a dentist in our dentist network
- Eye care: we cover one eye test for each person if you go to an eye doctor in our network and choose from a specific range of glasses or contact lenses
- Trauma Recovery Extender Benefit: we will cover specific out-of-hospital claims for your recovery after certain traumatic events. We’ll cover you for the rest of the year in which the trauma took place, and in the year after your trauma.
- Medical equipment: we cover wheelchairs, wheelchair batteries and cushions, transfer boards and mobile ramps, commodes, long-leg calipers, crutches and walkers on the medical equipment list, if you get them from a network provider. There is an overall limit of R4 450 for each family.
We pay medicine up to a maximum of Discovery Health Rate for medicines.
What if you need to see a specialist?
All KeyCare members have access to our Specialist Benefit. Your GP must contact us before your visit to a specialist to get a valid specialist reference number.
- You’re covered up to R2 750 for each person
Note: Any x-rays, blood tests or medicine that you need during your specialist visit will add up to the R2 750 limit for each person. We only pay for medicine on our medicine list.
Are there healthcare professionals we don’t cover?
Yes. We don’t cover the following from your day-to-day benefits:
- Speech therapists
Note: There may be other healthcare professionals or procedures we don’t cover.
Call us on 0860 99 88 77 to find out more about other exclusions.
Screening and prevention
What is your benefit for screening and prevention?
The screening and prevention benefit covers all KeyCare members.
If you go for certain tests to check your health, we will cover them if you go to a Discovery Wellness Network provider.
What screening tests can you have done?
- Blood glucose
- Blood pressure
- Body Mass Index (BMI)
What else is covered under this benefit?
We also cover the following:
- For females: Mammogram
- For females: Pap smear
- For males: PSA (prostrate screening test)
- For adult members: HIV screening tests
For KeyCare members 65 years or older and members registered for certain chronic conditions, we also cover a seasonal injection to prevent flu.
Are there treatments in hospital that we do not cover?
Yes. In addition to the general exclusions that apply to all plans, KeyCare Plans do not cover the following, except if the Prescribed Minimum Benefits says we must:
- Hospital admissions related to:
- skin disorders
- investigations and diagnostic work-up
- functional nasal surgery
- elective caesarean section, except if medically necessary
- surgery for oesophageal reflux and hiatus hernia
- back and neck treatment or surgery
- joint replacements, including but not limited to hips, knees, shoulders and elbows
- cochlear implants, auditory brain implants and internal nerve stimulators – this includes procedures, devices and processors
- healthcare services that should be done out of hospital and for which an admission to hospital is not necessary
- Removal of varicose veins
- Refractive eye surgery
- Non-cancerous breast conditions
- Healthcare services outside South Africa
We also do not cover the cost of treatment for any complications or the direct or indirect expenses related to any of these excluded conditions and treatments.
Read the full list of exclusions.
Monthly contributions based on average monthly income*
|KeyCare Plus||Main member||Adult||Child**|
|Income of R8 801+||R1 448||R1 448||R388|
|Income of R6 651 - R8 800||R973||R973||R272|
|Income of R0 - R6 650||R695||R695||R251|
|KeyCare Access||Main member||Adult||Child**|
|Income of R8 801+||R1 416||R1 416||R381|
|Income of R6 651 - R8 800||R942||R942||R267|
|Income of R4 151 - R6 650||R653||R653||R235|
|Income of R0- R4 150||R490||R490||R212|
|KeyCare Core||Main member||Adult||Child**|
|Income of R8 801+||R1 070||R1 070||R241|
|Income of R6 651 - R8 800||R693||R693||R171|
|Income of R0 - R6 650||R556||R556||R143|
*Income refers to the higher of the principal member's or spouse's average monthly earnings over the last 12 months from guaranteed earnings, guaranteed allowances, company contributions and variable pay or commissions from employment (including self-employment and informal employment), pension and annuity proceeds, interest earned on active and passive investments, rental income from leasing properties and distributions received from a trust.
**We count a maximum of three children when we work out the monthly contributions.