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Chronic Conditions

Being told you have a chronic condition or disease can be difficult and even scary. The good news is that KeyHealth is committed to helping members with chronic conditions and diseases to receive the best quality healthcare treatment and medication.
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A chronic condition is a health condition or disease that is persistent or otherwise long-lasting in its effects or a disease that comes with time. The term chronic is often applied when the course of the disease lasts for more than 3 months, for example, diabetes, HIV /AIDS and heart conditions.

Our Chronic Condition Benefits

Chronic Condition Benefits

Essence

Essence is the ideal ‘just-in-case’ medical cover for individuals starting out and for those who only need that crucial cover for emergencies and unexpected medical expenses.

Members on Essence are covered for:

  • 26 PMB CDL conditions
Chronic Condition Benefits

Origin

Origin is the comprehensive medical cover for anyone who has basic in and out of hospital needs for themselves or the people they care for.

Members on Origin are covered for:

  • 26 PMB CDL conditions 
Chronic Condition Benefits

Equilibrium

Equilibrium is the peace-of-mind-and-body medical cover for those looking for stability with extra security.

Members on Equilibrium are covered for: 

  • 26 PMB CDL conditions 
  • 4 additional chronic conditions
Chronic Condition Benefits

Silver

Silver is the step-up medical cover for individuals and families who expect more than the usual.

Members on Silver are covered for:

  • 26 PMB CDL conditions 
  • 4 additional chronic conditions
Chronic Condition Benefits

Gold

Gold is the superior medical cover for individuals and families who demand both substantial cover and security from their plans.

Members on Gold are covered for:

  • 26 PMB CDL conditions
  • 18 additional chronic conditions 
Chronic Condition Benefits

Platinum

Platinum is the top tier of medical cover for people who want it all taken care of, now and in the future.

Members on Platinum are covered for:

  • 26 PMB CDL conditions
  • 27 additional chronic conditions 

PMB chronic benefits

Members across all benefits options are covered for the 26 PMB CDL conditions (below).

26 PMB CDL conditions
  1. Addison’s Disease
  2. Asthma
  3. Bipolar Mood Disorder
  4. Bronchiectasis
  5. Cardiac Failure
  6. Cardiomyopathy Disease
  7. Chronic Renal Disease
  8. Coronary Artery Disease
  9. Crohn’s Disease
  10. Chronic Obstructive Pulmonary Disorder
  11. Diabetes Insipidus
  12. Diabetes Mellitus Type 1 & 2
  13. Dysrhythmias
  14. Epilepsy
  15. Glaucoma
  16. Haemophilia
  17. Hyperlipidaemia
  18. Hypertension
  19. Hypothyroidism
  20. Hormone Replacement Therapy (HRT)*
  21. Multiple Sclerosis
  22. Parkinson’s Disease
  23. Rheumatoid Arthritis
  24. Schizophrenia
  25. Systemic Lupus Erythematosus
  26. Ulcerative Colitis

*An additional chronic condition approved by the Scheme

PMB CDL clinical entry criteria

The clinical entry criteria for registering a condition typically involves a combination of medical history, diagnostic tests, and clinical assessments. These criteria ensure that the condition is well-defined, accurately registered and that the patient qualifies for the treatment or benefits associated with the condition.

Click to download the Clinical entry criteria

Auto authorisation of certain chronic conditions

  • Some chronic conditions / medications can be automatically authorised when the correct ICD-10 code is provided.
  • To ensure seamless processing, the treating provider must include the appropriate ICD-10 code on the prescription.
  • The pharmacist must capture this ICD-10 code when submitting the claim to the Scheme.
Read More

Additional chronic conditions

These are additional chronic conditions that the Scheme has added to help its members.

Equilibrium and Silver – 4 additional chronic conditions
  1. Acne
  2. Hyperkinesis / Attention Deficit Disorder (ADD)
  3. Rhinitis
  4. Major Depression
  • Acne and Hyperkinesis and/or ADD (Attention Deficit Disorder) are only covered for children up to the age of 21 years
  • Allergic Rhinitis and Major Depression are covered for all ages
Gold – 18 additional chronic conditions
  1. Allergic Rhinitis
  2. Benign Prostatic Hypertrophy
  3. Diverticulitis and Irritable Bowel Syndrome
  4. Gastroesophageal Reflux Disease
  5. Hypoparathyroidism#
  6. Hyperkinesis / Attention Deficit Disorder (ADD)
  7. Hyperthyroidism
  8. Iron deficiency anaemia
  9. Major Depression#
  10. Meniere’s Disease
  11. Migraine
  12. Osteoarthritis
  13. Paraplegia, Quadriplegia#
  14. Peripheral Vascular Disease#
  15. Rheumatic fever
  16. Testosterone deficiency
  17. Urinary incontinence

#Chronic medication for these PMB conditions (only for severe, life-threatening cases and motivated by the appropriate specialist), above the PMB level of care, will be paid at 100% of the cost

Platinum – 27 additional chronic conditions
  1. Acne
  2. Allergic Rhinitis
  3. Alzheimer’s Disease
  4. Ankylosing Spondylitis
  5. Benign Prostatic Hypertrophy
  6. Clotting Disorders (additional)
  7. Cystic Fibrosis
  8. Deep Vein Thrombosis#
  9. Stroke#
  10. Gastro-Oesophageal Reflux Disease
  11. Hypoparathyroidism#
  12. Hyperkinesis / Attention Deficit Disorder (ADD)
  13. Hyperthyroidism
  14. Interstitial Fibrosis
  15. Iron Deficiency Anaemia
  16. Major Depression#
  17. Meniere’s Disease
  18. Testosterone Deficiency
  19. Menopausal Disorder (Calcium only)#
  20. Migraine
  21. Myasthenia Gravis
  22. Osteoarthritis
  23. Osteoporosis
  24. Paraplegia, Quadriplegia#
  25. Peripheral Vascular Disease#
  26. Psoriasis
  27. Urinary Incontinence

#Chronic medication for PMB conditions (only for severe, life-threatening cases and motivated by the appropriate specialist), above the PMB level of care, will be paid at 100% of the cost.

Essence Dental Benefits

KeyHealth Hospital Network

  • Members on the Essence option must use a hospital within the KeyHealth Hospital Network for the removal of impacted teeth under General Anaesthetic.
  • Should a member make use of a non-network hospital, they will pay a 30% co-payment on the hospital account.
  • In case of an emergency or Prescribed Minimum Benefits (PMB) admission, a member may be admitted to any private hospital without having to pay a non-network co-payment.
  • Scheme Exclusions apply to dental benefits.
  • In the event of a dispute, the Rules of the Scheme will prevail.
  • Except for the pre-authorised removal of impacted teeth, all dental claims will be paid from the day-to-day family limit.

Conservative Dentistry

*Subject to Day-to-day Family Limit

Consultations
  • One check-up pbpa
  • Two infection control / barrier techniques pbpa
  • One sterilised instrumentation pbpa
X-rays: Intraoral
  • Four intraoral radiographs per beneficiary per year – periapical or bitewing

Hospitalisation and Anaesthetics

Hospitalisation (General Anaesthetic)

Pre-authorisation required

  • Admission protocols apply
  • Benefit subject to managed care protocols
  • ONLY for the removal of impacted teeth under General Anaesthetic
  • R1 890 co-payment per hospital admission (no co-payment for day hospitals)
Inhalation Sedation in the Dental Rooms

Pre-authorisation required

  • ONLY for the removal of impacted teeth
Moderate/Deep Sedation in the Dental Rooms

Pre-authorisation required

  • ONLY for the removal of impacted teeth

Dental Benefit Exclusion - Essence

Scheme Exclusions apply to dental benefits. The following exclusions apply to this option:

Conservative Dentistry
  • X-rays: Extraoral
  • Preventative Care
    • Oral hygiene instruction
    • Oral hygiene evaluation
    • Professionally applied fluoride for beneficiaries younger than 5, and 13 years and older
    • Tooth Whitening
  • Fillings
    • Fillings to restore teeth damaged due to toothbrush abrasion, attrition, erosion, and fluorosis
    • Resin bonding for restorations that are charged as a separate procedure to the restoration
    • The polishing of restorations
    • Gold foil restorations
    • Ozone therapy

Extractions

Specialised Dentistry
  • Root Canal Therapy
  • Plastic Dentures and Associated Laboratory Costs
  • Partial Chrome Cobalt Frame Dentures and Associated Laboratory Costs
  • Crowns and Associated Laboratory Costs
  • Orthodontics and Associated Laboratory Costs
  • Periodontics
  • Implants and Associated Laboratory Costs
  • Maxillo-facial Surgery and Oral Pathology
Click here for all Dental Benefit Exclusions

Origin Dental Benefits

KeyHealth Hospital Network

  • Members on the Origin option must use a hospital within the KeyHealth Hospital Network for the removal of impacted teeth under General Anaesthetic.
  • Should a member make use of a non-network hospital, they will pay a 30% co-payment on the hospital account.
  • In case of an emergency or Prescribed Minimum Benefits (PMB) admission, a member may be admitted to any private hospital without having to pay a non-network co-payment.
  • Scheme Exclusions apply to dental benefits.
  • In the event of a dispute, the Rules of the Scheme will prevail.
  • Except for the pre-authorised removal of impacted teeth, all dental claims will be paid from the day-to-day family limit.

Day-to-day Family Limit

  • All out-of-hospital benefits accumulate to the Day-to-day Family Limit.
  • As this is a family benefit, it means that one member of the family can use the total benefit allocation.

The limit will be calculated as follows:

  • Principal Member: R3 150 per year
  • Adult Dependant: R1 830 per year
  • Child Dependant: R965 per year

Conservative Dentistry

*Subject to Day-to-day Family Limit

Consultations
  • One check-up per beneficiary per year
  • Three specific (emergency) consultations per beneficiary per year
  • Benefit subject to managed care protocols
X-rays: Intraoral
  • Four X-rays per beneficiary per year
  • Benefit subject to managed care protocols
X-rays: Extraoral
  • One per beneficiary in a 3-year period
  • Benefit subject to managed care protocols
Preventative Care

Benefit for scale and polish:

  • One scale and polish treatment per beneficiary per year (once every 6 months)

Benefit for fissure sealants:

  • Limited to beneficiaries younger than 16 years of age

Benefit for fluoride:

  • Limited to beneficiaries from age 5 and younger than 13 years of age
  • Benefit subject to managed care protocols

Scheme Exclusions:

  • Oral hygiene instruction
  • Oral hygiene evaluation
  • Professionally applied fluoride for beneficiaries younger than 5, and 13 years and older
  • Tooth Whitening
Fillings

Benefit for fillings:

  • Granted once per tooth in 720 days

Benefit for re-treatment of a tooth:

  • Subject to managed care protocols

Multiple fillings:

  • A treatment plan and X-rays may be required for multiple fillings

Scheme Exclusions:

  • Fillings to restore teeth damaged due to toothbrush abrasion, attrition, erosion, and fluorosis
  • Resin bonding for restorations that are charged as a separate procedure to the restoration
  • The polishing of restorations
  • Gold foil restorations
  • Ozone therapy
Extractions

Benefit subject to managed care protocols Covered at 100% of the KeyHealth Dental Tariff

Hospitalisation and Anaesthetics

Hospitalisation (General Anaesthetic)

Pre-authorisation required

  • Admission protocols apply
  • Benefit subject to managed care protocols
  • ONLY for the removal of impacted teeth under General Anaesthetic
  • R1 890 co-payment per hospital admission (no co-payment for day hospitals).
Inhalation Sedation in the Dental Rooms

Pre-authorisation required

  • ONLY for the removal of impacted teeth
Moderate/Deep Sedation in the Dental Rooms

Pre-authorisation required

  • ONLY for the removal of impacted teeth

Dental Benefit Exclusion - Origin

Scheme Exclusions apply to dental benefits. The following exclusions apply to this option:

Specialised Dentistry
  • Root Canal Therapy
  • Plastic Dentures and Associated Laboratory Costs
  • Partial Chrome Cobalt Frame Dentures and Associated Laboratory Costs
  • Crowns and Associated Laboratory Costs
  • Orthodontics and Associated Laboratory Costs
  • Periodontics
  • Implants and Associated Laboratory Costs
  • Maxillo-facial Surgery and Oral Pathology
Click here for all Dental Benefit Exclusions

Equilibrium Dental Benefits

KeyHealth Hospital Network

  • Members on the Equilibrium option must use a hospital within the KeyHealth Hospital Network for planned procedures.
  • Should a member on the Equilibrium option use a non-network hospital, they will pay a 30% co-payment on the hospital account.
  • In case of an emergency or Prescribed Minimum Benefits (PMB) admission, a member on this option may be admitted to any private hospital without having to pay a non-network co-payment.

Pre-authorisation*

  • Dentures must be pre-authorised on the Equilibrium option.
  • Hospitalisation and certain specialised dentistry procedures and treatment must be pre-authorised.
  • If authorisation is applied for after the treatment has been done, the member will pay a 20% penalty fee.
  • This also applies to Hospitalisation (the hospital account) and Moderate/Deep Sedation in the dental rooms.
  • Failure to pre-authorise orthodontic treatment will result in a payment only from date of authorisation for the remaining months of treatment, provided that the treatment is approved as per the managed care protocols.
  • Penalties do not apply to emergency hospital admission.

Conservative Dentistry

Consultations
  • One check-up per beneficiary per year
  • Three specific (emergency) consultations per beneficiary per year
  • Benefit subject to managed care protocols
X-rays: Intraoral
  • Four X-rays per beneficiary per year
  • Benefit subject to managed care protocols
X-rays: Extraoral
  • One per beneficiary in a 3-year period
  • Additional benefit may be granted where specialised dental treatment is required.
  • Benefit subject to managed care protocols
Preventative Care

Benefit for scale and polish:

  • One scale and polish treatment per beneficiary per year (once every 6 months)

Benefit for fissure sealants:

  •  Limited to beneficiaries younger than 16 years of age

Benefit for fluoride:

  • Limited to beneficiaries from age 5 and younger than 13 years of age
  • Benefit subject to managed care protocols

Scheme Exclusions:

  • Oral hygiene instruction
  • Oral hygiene evaluation
  • Professionally applied fluoride for beneficiaries younger than 5, and 13 years and older
  • Tooth Whitening
Fillings

Benefit for fillings:

  • Granted once per tooth in 720 days

Benefit for re-treatment of a tooth:

  • Subject to managed care protocols

Multiple fillings:

  • A treatment plan and X-rays may be required for multiple fillings

Scheme Exclusions:

  • Fillings to restore teeth damaged due to toothbrush abrasion, attrition, erosion and
    fluorosis
  • Resin bonding for restorations that are charged as a separate procedure to the
    restoration
  • The polishing of restorations
  • Gold foil restorations
  • Ozone therapy
Root Canal Therapy and Extractions
  • Benefit subject to Managed Care Protocol

Scheme Exclusions:

  • Root canal therapy on primary (milk) teeth
  • Root canal therapy on third molars (wisdom teeth)
  • Direct and indirect pulp capping procedures
Plastic Dentures and Associated Laboratory Costs
  • Pre-authorisation required
  • One set of plastic dentures (an upper and a lower) per beneficiary in a 4-year period
  • Benefit not available for the clinical fee of denture repairs, denture tooth replacements and the addition of a soft base to new dentures; the laboratory fee will be covered (no pre-authorisation required)
  • Benefit for a mouth guard:
    • Benefit available for both the clinical and the associated laboratory fee for a mouth guard (no pre-authorisation required)
    • Benefit is subject to managed care protocols

Scheme Exclusions:

  • Diagnostic dentures and associated laboratory costs
  • Snoring appliances and associated laboratory costs
  • High impact acrylic
  • The cost of gold, precious metal, semi-precious metal, and platinum foil
  • Laboratory delivery fees
  • Provisional dentures and associated laboratory costs

Specialised Dentistry

Orthodontics and Associated Laboratory Costs

Pre-authorisation required subject to 20% co-payment 

  • Benefit for orthodontic treatment granted once per beneficiary per lifetime
  • Only one family member may start orthodontic treatment in a calendar year
  • On pre-authorisation, cases will be clinically assessed by using an orthodontic needs analysis.
  • Benefit allocation is subject to the outcome of the needs analysis.
  • Benefit for orthodontic treatment will be granted where function is impaired
  • Benefit will not be granted where orthodontic treatment is required for cosmetic reasons. The associated laboratory costs will also not be covered

Benefit for fixed comprehensive treatment:

  • Limited to individuals from age 9 and younger than 18 years of age
  • Benefit subject to managed care protocols

Scheme Exclusions:

  • Orthognathic (jaw correction) and other orthodontic related surgery, and any associated hospital and laboratory costs
  • Orthodontic re-treatment and any related laboratory costs
  • Invisible retainer material
  • Laboratory delivery fees
Maxillo-facial Surgery and Oral Pathology

Surgery in the dental chair:

  • Removal of impacted teeth only
  • Benefit subject to managed care protocols

Benefit for the closure of an oral-antral opening (code 8909):

  • Subject to motivation and managed care protocols

Surgery in hospital:

  • See Hospitalisation* below

Scheme Exclusions:

  • Orthognathic (jaw correction) surgery
  • Sinus lifts
  • Bone augmentations
  • Bone and tissue regeneration procedures
  • Cost of bone regeneration material
  • Auto-transplantation of teeth

Hospitalisation and Anaesthetics

Hospitalisation (General Anaesthetic)

Pre-authorisation required

  • Admission protocols apply
  • Benefit subject to managed care protocols
  • General anaesthetic benefit available for children under the age of 5 years for extensive dental treatment
  • General anaesthetic benefit available for the removal of impacted teeth
  • R1 890 co-payment per hospital admission (no co-payment for day hospitals)
  • The hospital and anaesthetist claims for the procedures listed below will not be covered when performed under general anaesthesia. The payment of the dental procedure will be dependent on available benefits, and payable at the KeyHealth Dental Tariff:
    • Apicectomies
    • Dentectomies
    • Frenectomies
    • Implantology and associated surgical procedures
    • Conservative dental treatment (fillings, extractions, and root canal therapy) for adults
    • Professional oral hygiene procedures
    • Surgical tooth exposures for orthodontic reasons

Scheme Exclusions:

  • Where the only reason for admission to hospital is dental fear and anxiety
  • Multiple hospital admissions
  • Where the only reason for the admission request is for a sterile facility
  • The cost of dental materials for procedures performed under general anaesthesi
Inhalation Sedation in the Dental Rooms

Pre-authorisation required

  • Benefit subject to managed care protocols
Moderate/deep Sedation in the Dental Rooms

Pre-authorisation required

  • Benefit limited to extensive dental treatment
  • Benefit subject to managed care protocols

Dental Benefit Exclusion – Equilibrium

Specialised Dentistry
  • Partial Chrome Cobalt Frame Dentures and Associated Laboratory Costs
  • Crowns and Associated Laboratory Costs
  • Periodontics
  • Implants and Associated Laboratory Costs
Click here for all Dental Benefit Exclusions

Silver Dental Benefits

KeyHealth Hospital Network

  • Members on the Silver option must use a hospital within the KeyHealth Hospital Network for planned procedures.
  • Should a member make use of a non-network hospital, they will pay a 30% co-payment on the hospital account.
  • In case of an emergency or Prescribed Minimum Benefits (PMB) admission, a member on these options may be admitted to any private hospital without having to pay a non-network co-payment.

Pre-authorisation*

  • Dentures must be pre-authorised on this option.
  • Hospitalisation and certain specialised dentistry procedures and treatment must be pre-authorised.
  • If authorisation is applied for after the treatment has been done, a member will pay a 20% penalty fee.
  • This applies to hospitalisation (the hospital account) and Moderate/Deep Sedation.
  • Failure to pre-authorise orthodontic treatment will result in a payment only from date of authorisation for the remaining months of treatment, provided that the treatment is approved as per the managed care protocols.
  • Penalties do not apply to emergency hospital admission.

Conservative Dentistry

Consultations
  • Two check-ups per beneficiary per year (once every 6 months)
  • Benefit subject to pre-authorisation
  • Benefit subject to managed care protocols
X-rays: Intraoral
  • Benefit subject to pre-authorisation
X-rays: Extraoral
  • One per beneficiary over a 3-year period
  • Additional benefit may be granted where specialised dental treatment is required.
  • Benefit subject to pre-authorisation
Preventative Care

Benefit for scale and polish:

  • Two scale and polish treatments per beneficiary per year (once every 6 months)

Benefit for fissure sealants:

  • Limited to beneficiaries younger than 16 years of age

Benefit for fluoride:

  • Limited to beneficiaries from age 5 and younger than 13 years
  • Benefit subject to managed care protocols

Scheme Exclusions:

  • Oral hygiene instruction
  • Oral hygiene evaluation
  • Professionally applied fluoride for beneficiaries younger than 5, and 13 years and older
  • Tooth Whitening
Fillings

Benefit for fillings:

  • Granted once per tooth in 720 days

Benefit for re-treatment of a tooth:

  • Subject to managed care protocols

Multiple fillings:

  • A treatment plan and X-rays may be required

Scheme Exclusions:

  • Fillings to restore teeth damaged due to toothbrush abrasion, attrition, erosion, and fluorosis
  • Resin bonding for restorations that are charged as a separate procedure to the restoration
  • The polishing of restorations
  • Gold foil restorations
  • Ozone therapy
Root Canal Therapy and Extractions
  • Subject to managed care protocols

Scheme Exclusions:

  • Root canal therapy on primary (milk) teeth
  • Root canal therapy on third molars (wisdom teeth)
  • Direct and indirect pulp capping procedures
Plastic Dentures and Associated Laboratory Costs

Pre-authorisation required

  • One set of plastic dentures (an upper and a lower) per beneficiary over a 4 year period
  • Benefit not available for the clinical fee of denture repairs, denture tooth replacements and the addition of a soft base to new dentures; the laboratory fee will be covered (no pre-authorisation required).
  • Benefit for a mouth guard:
    • Benefit available for both the clinical and the associated laboratory fee for a mouth guard (no pre-authorisation required)
    • Benefit is subject to managed care protocols

Scheme Exclusions:

  • Diagnostic dentures and associated laboratory costs
  • Provisional dentures and associated laboratory costs
  • Snoring appliances and associated laboratory costs
  • High impact acrylic
  • The cost of gold, precious metal, semi-precious metal and platinum foil
  • Laboratory delivery fees

Specialised Dentistry

Orthodontics and Associated Laboratory Costs

Pre-authorisation required, subject to 20% co-payment 

  • Benefit for orthodontic treatment granted once per beneficiary per lifetime.
  • Only one family member may start orthodontic treatment in a calendar year.
  • On pre-authorisation, cases will be clinically assessed by using an orthodontic needs analysis.
  • Benefit allocation is subject to the outcome of the needs analysis.
  • Benefit for orthodontic treatment will be granted where function is impaired.
  • Benefit will not be granted where orthodontic treatment is required for cosmetic reasons. The associated laboratory costs will also not be covered.
  • Benefit for fixed comprehensive treatment: Limited to individuals from age 9 and younger than 18 years of age
  • Benefit subject to managed care protocols

Scheme Exclusions:

  • Orthognathic (jaw correction) and other orthodontic related surgery, and any associated hospital and laboratory costs
  • Orthodontic re-treatment and any related laboratory costs
  • Invisible retainer material
  • Laboratory delivery fees
Maxillo-facial Surgery and Oral Pathology

Surgery in the dental chair:

  • Benefit subject to managed care protocols

Benefit for Temporo-mandibular Joint (TMJ) therapy:

  • Limited to non-surgical intervention/ treatments.

Oral pathology procedures (cysts and biopsies, the surgical treatment of tumours of the jaw and soft tissue tumours):

  • Claims will only be covered if supported by a laboratory report that confirms diagnosis
  • Benefit for the closure of an oral-antral opening (code 8909): Subject to motivation and managed care protocols

Surgery in hospital:

  • See Hospitalisation* below

Scheme Exclusions:

  • Orthognathic (jaw correction) surgery
  • Sinus lifts
  • Bone augmentations
  • Bone and tissue regeneration procedures
  • Cost of bone regeneration material
  • Auto-transplantation of teeth

Hospitalisation and Anaesthetics

Hospitalisation (General Anaesthetic)

Pre-authorisation required

  • Admission protocols apply
  • Benefit subject to managed care protocols
  • General anaesthetic benefit available for children under the age of 5 years for extensive dental treatment
  • General anaesthetic benefit available for the removal of impacted teeth
  • R1 890 co-payment per hospital admission (no co-payment for day hospitals)
  • The hospital and anaesthetist claims for the procedures listed below will not be covered when performed under general anaesthesia. The payment of the dental procedure will be dependent on available benefits, and payable at the KeyHealth dental tariff:
    » Apicectomies
    » Dentectomies
    » Frenectomies
    » Implantology and associated surgical procedures
    » Conservative dental treatment (fillings, extractions and root canal therapy) for adults
    » Professional oral hygiene procedures
    » Surgical tooth exposures for orthodontic reasons

Scheme Exclusions:

  • Where the only reason for admission to hospital is dental fear and anxiety
  • Multiple hospital admissions
  • Where the only reason for the admission request is for a sterile facility
  • The cost of dental materials for procedures performed under general anaesthesia
Inhalation Sedation in the Dental Rooms

Pre-authorisation required

  • Benefit subject to managed care protocols
Moderate/Deep Sedation in the Dental Rooms

Pre-authorisation required

  • Benefit limited to extensive dental treatment
  • Benefit subject to managed care protocols

Dental Benefit Exclusion – Silver

Scheme Exclusions apply to dental benefits. The following exclusions apply to this option:

Specialised Dentistry
  • Partial Chrome Cobalt Frame Dentures and Associated Laboratory Costs
  • Crown & Bridge and Associated Laboratory Costs
  • Implants and Associated Laboratory Costs
  • Periodontics
Click here for all Dental Benefit Exclusions

Gold Dental Benefits

KeyHealth Hospital Network

  • Members on the Gold option must use a hospital within the KeyHealth Hospital Network for planned procedures.
  • Should a member make use of a non-network hospital, they will pay a 30% co-payment on the hospital account.
  • In case of an emergency or Prescribed Minimum Benefits (PMB) admission, a member on these options may be admitted to any private hospital without having to pay a non-network co-payment.

Pre-authorisation*

  • Dentures must be pre-authorised on this option.
  • Hospitalisation and certain specialised dentistry procedures and treatment must be pre-authorised.
  • If authorisation is applied for after the treatment has been done, a member will pay a 20% penalty fee.
  • This is applies to hospitalisation (the hospital account) and Moderate/Deep Sedation.
  • Failure to pre-authorise orthodontic treatment will result in a payment only from date of authorisation for the remaining months of treatment, provided that the treatment is approved as per the managed care protocols.
  • Penalties do not apply to emergency hospital admission.

Conservative Dentistry

Consultations
  • Two check-ups per beneficiary per year (once every 6 months)
  • Benefit subject to managed care protocols
X-rays: Intraoral
  • Benefit subject to pre-authorisation
X-rays: Extraoral
  • One per beneficiary over a 3-year period
  • Additional benefit may be granted where specialised dental treatment is required
  • Benefit subject to managed care protocols
Preventative Care

Benefit for scale and polish:

  • Two scale and polish treatments per beneficiary per year (once every 6 months)

Benefit for fissure sealants:

  • Limited to beneficiaries younger than 16 years of age

Benefit for fluoride:

  • Limited to beneficiaries from age 5 and younger than 13 years of age
  • Benefit subject to managed care protocols

Scheme Exclusions:

  • Oral hygiene instruction
  • Oral hygiene evaluation
  • Professionally applied fluoride for beneficiaries younger than 5, and 13 years and older
  • Tooth Whitening
Fillings

Benefit for fillings:

  • Granted once per tooth in 720 days
  • Benefit for re-treatment of a tooth
  • Benefit subject to managed care protocols

Multiple fillings:

  • A treatment plan and X-rays may be required

Scheme Exclusions:

  • Fillings to restore teeth damaged due to toothbrush abrasion, attrition, erosion, and fluorosis
  • Resin bonding for restorations that are charged as a separate procedure to the restoration
  • The polishing of restorations
  • Gold foil restorations
  • Ozone therapy
Root Canal Therapy and Extractions
  • Benefit subject to managed care protocols

Scheme Exclusions:

  • Root canal therapy on primary (milk) teeth
  • Root canal therapy on third molars (wisdom teeth)
  • Direct and indirect pulp capping procedures
Plastic Dentures and Associated Laboratory Costs

Pre-authorisation required

  • One set of plastic dentures (an upper and a lower) per beneficiary over a 4-year period
  • Benefit not available for the clinical fee of denture repairs, denture tooth
    replacements and the addition of a soft base to new dentures; the laboratory fee will be covered (no pre-authorisation required)
  • Benefit for a mouth guard:
    • Benefit available for both the clinical and the associated laboratory fee for a mouth guard (no pre-authorisation required)
    • Benefit is subject to managed care protocols

Scheme Exclusions:

  • Diagnostic dentures and associated laboratory costs
  • Provisional dentures and associated laboratory costs
  • Snoring appliances and associated laboratory costs
  • High impact acrylic
  • The cost of gold, precious metal, semi-precious metal and platinum foil
  • Laboratory delivery fees

Specialised Dentistry

Partial Chrome Cobalt Frame Dentures and Associated Laboratory Costs

Pre-authorisation required, subject to 20% co-payment

  • One partial frame (an upper or a lower) per beneficiary over a 5-year period
  • Benefit subject to managed care protocols

Scheme Exclusions:

  • The metal base to full dentures and associated laboratory costs
  • High impact acrylic
  • The cost of gold, precious metal, semi-precious metal and platinum foil
  • Laboratory delivery fees
Crown & Bridge and Associated Laboratory Costs

A bridge comprises two or more crown units. Each crown is payable from the available Crown & Bridge benefit.

Pre-authorisation required, subject to 20% co-payment

  • Benefit for crowns will be granted once per tooth over a 5-year period
  • A treatment plan and X-rays may be requested
  • Benefit subject to managed care protocols
  • A pontic on a 2nd molar, where the 3rd molar is a crown retainer, is subject to managed care protocols

Scheme Exclusions:

  • Crowns on third molars
  • Crown and bridge procedures for cosmetic reasons and associated laboratory costs
  • Laboratory fabricated temporary crowns
  • Occlusal rehabilitations and associated laboratory costs
  • Provisional crowns and associated laboratory costs
  • Porcelain veneers and inlays, and associated laboratory costs
  • Emergency crowns that are not placed for the immediate protection in tooth injury and associated laboratory costs
  • The cost of gold, precious metal, semi-precious metal and platinum foil
  • Laboratory delivery fees
Orthodontics and Associated Laboratory Costs

Pre-authorisation required, subject to 20% co-payment

  • Benefit for orthodontic treatment granted once per beneficiary per lifetime
  • Only one family member may start orthodontic treatment in a calendar year
  • On pre-authorisation, cases will be clinically assessed by using an orthodontic needs analysis.
  • Benefit allocation is subject to the outcome of the needs analysis.
  • Benefit for orthodontic treatment will be granted where function is impaired
  • Benefit will not be granted where orthodontic treatment is required for cosmetic reasons. The associated laboratory costs will also not be covered.
  • Benefit for fixed comprehensive treatment: Limited to individuals from age 9 and younger than 18 years of age
  • Benefit subject to managed care protocols

Scheme Exclusions:

  • Orthognathic (jaw correction) and other orthodontic-related surgery, and any associated hospital and laboratory costs
  • Orthodontic re-treatment and any related laboratory costs
  • Invisible retainer material
  • Laboratory delivery fees
Periodontics

Pre-authorisation required, subject to 20% co-payment

  • Benefit will only be applied to members registered on the Periodontal Programme
  • Benefit limited to conservative, non-surgical therapy only
  • Benefit subject to managed care protocols

Scheme Exclusions:

  • Surgical periodontics which includes gingivectomies, periodontal flap surgery, tissue grafting and the hemisection of a tooth
  • PerioChip placement
Maxillo-facial Surgery and Oral Pathology

Surgery in the dental chair:

  • Benefit subject to managed care protocols

Benefit for Temporo-mandibular Joint (TMJ) therapy:

  • Limited to non-surgical intervention / treatments.

Oral pathology procedures (cysts and biopsies, the surgical treatment of tumours of the jaw and soft tissue tumours):

  • Claims will only be covered if supported by a laboratory report that confirms diagnosis
  • Benefit for the closure of an oral-antral opening (code 8909): Subject to motivation and managed care protocols

Surgery in hospital:

  • See Hospitalisation* below

Scheme Exclusions:

  • Orthognathic (jaw correction) surgery
  • Sinus lifts
  • Bone augmentations
  • Bone and tissue regeneration procedures
  • Cost of bone regeneration material
  • Auto-transplantation of teeth

Hospitalisation and Anaesthetics

Hospitalisation (General Anaesthetic)

Pre-authorisation required

  • Admission protocols apply
  • Benefit subject to managed care protocols
  • General anaesthetic benefit available for children under the age of 5 years for extensive dental treatment
  • General anaesthetic benefit available for the removal of impacted teeth
  • R1 890 co-payment per hospital admission  (no co-payment for day hospitals)
  • The hospital and anaesthetist claims for the procedures listed below will not be covered when performed under general anaesthesia. The payment of the dental procedure will be dependent on available benefits, and payable at the KeyHealth dental tariff:
    • Apicectomies
    • Dentectomies
    • Frenectomies
    • Implantology and associated surgical procedures
    • Conservative dental treatment (fillings, extractions and root canal therapy) for adults
    • Professional oral hygiene procedures
    • Surgical tooth exposures for orthodontic reasons

Scheme Exclusions:

  • Where the only reason for admission to hospital is dental fear and anxiety
  • Multiple hospital admissions
  • Where the only reason for the admission request is for a sterile facility
  • The cost of dental materials for procedures performed under general anaesthesia
Inhalation Sedation in the Dental Rooms

Pre-authorisation required

  • Benefit subject to managed care protocols
Moderate/Deep Sedation in the Dental Rooms

Pre-authorisation required

  • Benefit limited to extensive dental treatment
  • Benefit subject to managed care protocols

Dental Benefit Exclusion – Gold

Scheme Exclusions apply to dental benefits. The following exclusions apply to this option:

Specialised Dentistry
  • Implants and Associated Laboratory Costs
Click here for all Dental Benefit Exclusions

Platinum Dental Benefits

KeyHealth Hospital Network

  • Members on the Platinum option must use a hospital within the KeyHealth Hospital Network for planned procedures.
  • Should a member make use of a non-network hospital, they will pay a 30% co-payment on the hospital account.
  • In case of an emergency or Prescribed Minimum Benefits (PMB) admission, a member on these options may be admitted to any private hospital without having to pay a non-network co- payment.

Pre-authorisation*

  • Dentures must be pre-authorised on this option.
  • Hospitalisation and certain specialised dentistry procedures and treatment must be pre-authorised.
  • If authorisation is applied for after the treatment has been done, a member will pay a 20% penalty fee.
  • This is applies to hospitalisation (the hospital account) and Moderate/Deep Sedation.
  • Failure to pre-authorise orthodontic treatment will result in a payment only from date of authorisation for the remaining months of treatment, provided that the treatment is approved as per the managed care protocols.
  • Penalties do not apply to emergency hospital admission.

Conservative Dentistry

Consultations
  • Two check-ups per beneficiary per year (once every 6 months)
  • Benefit subject to managed care protocols
X-rays: Intraoral
  • Benefit subject to pre-authorisation
X-rays: Extraoral
  • One per beneficiary over a 3-year period
  • Additional benefit may be granted where specialised dental treatment is required.
  • Benefit subject to managed care protocols
Preventative Care

Benefit for scale and polish:

  • Two scale and polish treatments per beneficiary per year (once every 6 months)

Benefit for fissure sealants:

  • Limited to beneficiaries younger than 16 years of age

Benefit for fluoride:

  • Limited to beneficiaries from age 5 and younger than 13 years of age
  • Benefit subject to managed care protocols

Scheme Exclusions:

  • Oral hygiene instruction
  • Oral hygiene evaluation
  • Professionally applied fluoride for beneficiaries younger than 5, and 13 years and older
  • Tooth Whitening
Fillings

Benefit for fillings:

  • Granted once per tooth in 720 days
  • Benefit for re-treatment of a tooth
  • Subject to managed care protocols

Multiple fillings:

  • A treatment plan and X-rays may be required

Scheme Exclusions:

  • Fillings to restore teeth damaged due to toothbrush abrasion, attrition, erosion, and fluorosis
  • Resin bonding for restorations that are charged as a separate procedure to the restoration
  • The polishing of restorations
  • Gold foil restorations
  • Ozone therapy
Root Canal Therapy and Extractions
  • Subject to managed care protocols

Scheme Exclusions:

  • Root canal therapy on primary (milk) teeth
  • Root canal therapy on third molars (wisdom teeth)
  • Direct and indirect pulp capping procedures
Plastic Dentures and Associated Laboratory Costs

Pre-authorisation required

  • One set of plastic dentures (an upper and a lower) per beneficiary over a 4-year period
  • Benefit not available for the clinical fee of denture repairs, denture tooth replacements and the addition of a soft base to new dentures; the laboratory fee will be covered (no pre-authorisation required)
  • Benefit for a mouth guard:
    • Benefit available for both the clinical and the associated laboratory fee for a mouth guard (no pre-authorisation required)
    • Benefit is subject to managed care protocols

Scheme Exclusions:

  • Diagnostic dentures and associated laboratory costs
  • Provisional dentures and associated laboratory costs
  • Snoring appliances and associated laboratory costs
  • High impact acrylic
  • The cost of gold, precious metal, semi-precious metal and platinum foil
  • Laboratory delivery fees

Specialised Dentistry

Partial Chrome Cobalt Frame Dentures and Associated Laboratory Costs

Pre-authorisation required, subject to 20% co-payment

  • Two partial frames (an upper or a lower) per beneficiary over a 5-year period
  • Benefit subject to managed care protocols

Scheme Exclusions:

  • The metal base to full dentures and associated laboratory costs
  • High impact acrylic
  • The cost of gold, precious metal, semi-precious metal and platinum foil
  • Laboratory delivery fees
Crown & Bridge and Associated Laboratory Costs

A bridge comprises two or more crown units. Each crown is payable from the available Crown & Bridge benefit.

Pre-authorisation required, subject to 20% co-payment

  • Benefit for crowns will be granted once per tooth over a 5-year period
  • A treatment plan and X-rays may be requested
  • Benefit subject to managed care protocols
  • A pontic on a 2nd molar, where the 3rd molar is a crown retainer, is subject to managed care protocols

Scheme Exclusions:

  • Crowns on third molars
  • Crown and bridge procedures for cosmetic reasons and associated laboratory costs
  • Laboratory fabricated temporary crowns
  • Occlusal rehabilitations and associated laboratory costs
  • Provisional crowns and associated laboratory costs
  • Porcelain veneers and inlays, and associated laboratory costs
  • Emergency crowns that are not placed for the immediate protection in tooth injury and associated laboratory costs
  • The cost of gold, precious metal, semi-precious metal and platinum foil
  • Laboratory delivery fees
Implants and Associated Laboratory Costs

Pre-authorisation required, subject to 20% co-payment

  • Cost of implant components limited to R5 000 per beneficiary per year
  • Benefit subject to managed care protocols

Scheme Exclusions:

  • Implants on third molars (wisdom teeth)
  • Laboratory delivery fees
Orthodontics and Associated Laboratory Costs

Pre-authorisation required, subject to 20% co-payment

  • Benefit for orthodontic treatment granted once per beneficiary per lifetime
  • Only one family member may start orthodontic treatment in a calendar year
  • On pre-authorisation, cases will be clinically assessed by using an orthodontic needs analysis
  • Benefit allocation is subject to the outcome of the needs analysis
  • Benefit for orthodontic treatment will be granted where function is impaired
  • Benefit will not be granted where orthodontic treatment is required for cosmetic reasons. The associated laboratory costs will also not be covered
  • Benefit for fixed comprehensive treatment: Limited to individuals from age 9 and younger than 18 years of age
  • Benefit subject to managed care protocols

Scheme Exclusions:

  • Orthognathic (jaw correction) and other orthodontic-related surgery, and any associated hospital and laboratory costs
  • Orthodontic re-treatment and any related laboratory costs
  • Invisible retainer material
  • Laboratory delivery fees
Periodontics

Pre-authorisation required, subject to 20% co-payment

  • Benefit will only be applied to members registered on the Periodontal Programme
  • Benefit limited to conservative, non-surgical therapy only
  • Benefit subject to managed care protocols

Scheme Exclusions:

  • Surgical periodontics which includes gingivectomies, periodontal flap surgery, tissue grafting and the hemisection of a tooth
  • PerioChip placement
Maxillo-facial Surgery and Oral Pathology

Surgery in the dental chair:

  • Benefit subject to managed care protocols

Benefit for Temporo-mandibular Joint (TMJ) therapy:

  • Limited to non-surgical intervention / treatments

Oral pathology procedures (cysts and biopsies, the surgical treatment of tumours of the jaw and soft tissue tumours):

  • Claims will only be covered if supported by a laboratory report that confirms diagnosis
  • Benefit for the closure of an oral-antral opening (code 8909): Subject to motivation and managed care protocols

Surgery in hospital:

  • See Hospitalisation* below

Scheme Exclusions:

  • Orthognathic (jaw correction) surgery
  • Sinus lifts
  • Bone augmentations
  • Bone and tissue regeneration procedures
  • Cost of bone regeneration material
  • Auto-transplantation of teeth

Hospitalisation and Anaesthetics

Hospitalisation (General Anaesthetic)

Pre-authorisation required

  • Admission protocols apply
  • Benefit subject to managed care protocols
  • General anaesthetic benefit available for children under the age of 5 years for extensive dental treatment
  • General anaesthetic benefit available for the removal of impacted teeth
  • R1 890 co-payment per hospital admission (no co-payment for day hospitals)
  • The hospital and anaesthetist claims for the procedures listed below will not be covered when performed under general anaesthesia. The payment of the dental procedure will be dependent on available benefits, and payable at the KeyHealth dental tariff:
    • Apicectomies
    • Dentectomies
    • Frenectomies
    • Implantology and associated surgical procedures
    • Conservative dental treatment (fillings, extractions and root canal therapy) for adults
    • Professional oral hygiene procedures
    • Surgical tooth exposures for orthodontic reasons

Scheme Exclusions:

  • Where the only reason for admission to hospital is dental fear and anxiety
  • Multiple hospital admissions
  • Where the only reason for the admission request is for a sterile facility
  • The cost of dental materials for procedures performed under general anaesthesia
Inhalation Sedation in the Dental Rooms

Pre-authorisation required

  • Benefit subject to managed care protocols

Moderate/Deep Sedation in the Dental Rooms

Pre-authorisation required

  • Benefit limited to extensive dental treatment
  • Benefit subject to managed care protocols
Click here for all Dental Benefit Exclusions

General Dental Benefit Exclusions

Oral Hygiene/Prevention
  • Oral hygiene instruction
  • Oral hygiene evaluation
  • Professionally applied fluoride for beneficiaries younger than 5 and 13 years and older
  • Tooth whitening
  • Nutritional and tobacco counselling
  • Cost of prescribed toothpastes, mouthwashes (e.g. Corsodyl) and ointments
  • Fissure sealants on patients 16 years and older
Fillings/Restorations
  • Fillings to restore teeth damaged due to toothbrush abrasion, attrition, erosion and fluorosis.
  • Resin bonding for restorations charged as a separate procedure to the restoration.
  • Polishing of restorations
  • Gold foil restorations
  • Ozone therapy
Root Canal Therapy and Extractions
  • Root canal therapy on primary (milk) teeth
  • Direct and indirect pulp capping procedures
  • Root canal therapy on 3rd molars (wisdom teeth)
Plastic Dentures/Snoring appliances/Mouthguards
  • Diagnostic dentures and the associated laboratory costs
  • Snoring appliances and the associated laboratory costs
  • he clinical fee of dental repairs, denture tooth replacements and the addition of a soft base to new dentures (The laboratory fee will be covered at the KeyHealth Dental Tariff where managed care protocols apply.)
  • High impact acrylic
  • Cost of gold, precious metal, semi-precious metal and platinum foil
  • Laboratory delivery fees
  • Provisional dentures and associated laboratory
Partial Chrome Cobalt Frame Dentures
  • Metal base to full dentures, including the laboratory cost.
  • High impact acrylic
  • Cost of gold, precious metal, semi-precious metal and platinum foil
  • Laboratory delivery fees
Crown and Bridge
  • Crowns on wisdom teeth (3rd molars)
  • Crown and bridge procedures for cosmetic reasons and the associated laboratory costs
  • Crown and bridge procedures where there is no extensive tooth structure loss and associated laboratory costs
  • Occlusal rehabilitations and the associated laboratory costs
  • Provisional crowns and the associated laboratory costs
  • Porcelain veneers and inlays/onlays and the associated laboratory costs
  • Emergency crowns that are not placed for immediate protection in tooth injury, and the associated laboratory costs.
  • Cost of gold, precious metal, semi-precious metal and platinum foil
  • Laboratory delivery fees
  • Laboratory fabricated temporary crowns
Implants
  • Laboratory delivery fees
Orthodontics
  • Orthodontic treatment for cosmetic reasons and associated laboratory costs
  • Individuals from age 9 and younger than 18 years
  • Orthodontic re-treatment and the associated laboratory costs
  • Cost of invisible retainer material
  • Laboratory delivery fees
Periodontics
  • Surgical periodontics, which includes gingivectomies, periodontal flap surgery, tissue grafting and hemisection of a tooth.
  • Peria chip placement
Maxilla-Facial Surgery and Oral Pathology
  • Bone augmentations
  • Bone and other tissue regeneration procedures
  • Cost of bone regeneration material
  • The auto-transplantation of teeth
  • Sinus lift procedures
  • The closure of an oral-antral opening (item code 8909) when claimed during the same visit with impacted teeth (item codes 8941, 8943 and 8945).
Hospitalisation (general anaesthetic)
  • Where the reason for admission to hospital is dental fear or anxiety
  • Multiple hospital admissions
  • Where the only reason for admission to hospital is to acquire a sterile facility
  • The cost of dental materials for procedures performed under general anaesthesia
  • The hospital and anaesthetist claims for the following procedures will not be covered when performed under general anaesthesia:
    • Apicectomies
    • Dentectomies
    • Frenectomies
    • Conservative dental treatment (fillings, extractions and root canal therapy) in hospital for adults
    • Professional oral hygiene procedures
    • lmplantology and associated surgical procedures
    • Surgical tooth exposure for orthodontic reasons

 

Additional scheme exclusions
  • Special reports
  • Dental testimony, including dentolegal fees
  • Behaviour management
  • Intramuscular and subcutaneous injections
  • Procedures that are defined as unusual circumstances and procedures that are defined as unlisted procedures
  • Appointments not kept
  • Electrognathographic recordings, pantographic recordings and other such electronic analyses
  • Caries susceptibility and microbiological tests
  • Pulp tests
  • Cost of mineral trioxide
  • Enamel microabrasion