Basic Information to Help You Compare Hospital Plans
At KeyHealth we make it easy to compare hospital plans as offered in our five cover packages. Simply look at the 2012 and 2013 benefits packages and review the differences among the packages. Some basic information is shared below to help you understand the limitations and terminologies used in the information packages and thus, also make it easier for you to compare our various hospital plans.
The reference prices stated in the hospital plans are the maximum amounts that we are willing to pay for treatments and drugs from the specific class listed on the Condition Medicine list for the particular condition. Note that different reference prices are applicable for each benefit package.
You as the patient can control spending because you do not have to select the medicine that is priced higher than the reference price. You can select an alternative medicine or generic. Ask your doctor, the pharmacist or the hospital staff about generics or alternative medication.
You can also choose to get the prescribed medicine even if such is priced higher than what we are willing to pay and then pay the extra cost. We review the reference price annually and then consider all the new drug entries and enhancements, license indications, generic influence, and price indications.
Pre-Authorisation for Hospitalisation and Treatments
You will note that we state for certain conditions that pre-authorisation may be required. We also require pre-authorisation for hospitalisation. You need to phone the provided number at our website before admission to the hospital to get the required authorisation.
Specific information will be needed such as the details of the medical service provider including practice number, initials and surname, and telephone number. You will also need to provide the date of admission as well as the date on which the procedure is scheduled to be performed and the reason for hospitalisation or planned diagnostic procedure. In addition, please note that the relevant CPT4 or ICD10 codes will be needed.
Other information that must be supplied:
- Full name of the patient
- Member number
- Practice number and name of the hospital
When your doctor thus recommends a procedure for which hospitalisation will be needed, enquire as to the reason, associated medical diagnosis, and planned procedures.
We process the information and then provide you with the required authorisation number. When you compare the hospital plans always check whether pre-authorisation is needed for a specific procedure as well.
Authorisation must be obtained a minimum of 24 hours before admission. We understand that in an emergency this may not be possible, but do then require that the authorisation is obtained within two working days after the emergency admission. If you are unable to notify us of such, one of your family members, the hospital or friend can do so on your behalf. If the proper authorisation is not obtained in the allocated time, we will not pay the relevant benefit costs.
Prescribed Minimum Benefits
Prescribed Minimum Benefits (PMB) refers to the minimum benefits payable for hospital care according to specific conditions according to the terms of the Medical Schemes Act No. 131 of 1998. A list of these conditions that are covered during hospitalisation can be obtained from the Council for Medical Schemes. These benefits apply regardless of the Scheme option that you select.
The costs associated with diagnosis, treatment, and care for emergency medical conditions as on the list must be covered. About 25 chronic diseases and around 270 medical conditions are covered. The medical practitioner treating the patient determines whether a condition meets the PMB requirements.
You will note when you compare the hospital plans that at specific treatments we have indicated that PMB conditions apply.
You will note that we state DSP hospitals for specific treatments according to benefits option. Services that qualify under PMB and rendered by the DSP hospitals are covered fully. The desired service providers appointed by KeyHealth are state facilities for any of the major medical conditions that fall within the PMB category and also the New National Hospital Network services providers for the benefits options of Silver, Bronze Plus and Bronze options.
View the various benefit options and compare the hospital plans to help you decide which option will be best for you and your family.