Keyhealth Equillibrium medical aid plan: 2017 v 2018

View all plans in this scheme.
Please note that these benefits are still being updated as more information is made available to us. Always consult with your broker before making final decisions regarding your healthcare cover.

COSTS and OVERVIEW:
Equilibrium
2018 costs In brief:
What’s new in 2018?
Main: Adult: Child:
Cost 2018: R1,936 R1,195 R593
Cost 2017: (R1,817) (R1,096) (R556)
Gap (optional): KaeloXelus: R350 per family
(R600 per family if anyone is 60yrs+)
Overal Limit: Unlimited
PMBs: Day-to-day expenses for PMBs (eg. cancer) are always paid for by the scheme, according to protocols. Find out more
Savings: R1,692 R1,044 R516
Extended Fund: R2,558 R1,756 R784
Children: Pay for maximum 3 children
  • There are no major changes to this plan in 2018, other than the usual monetary increases in premiums, benefits and co-payments

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Avoid bills! Get up to: 800% scheme rate;  R12,800 per ER visit; unlimited cancer cover;  

co-payments paid and cash payout for hospital stay. R350pm per family


IN HOSPITAL PROCEDURES:
Equilibrium
2017 v 2018 benefits Gap benefits Notes
Payout Rate for Specialists:
  • Up to 500% of scheme rate
  • In case of admission related to accident:
    • R300 per day, for days 1-13
    • R600 per day for days 14-20
    • R1,200 per day for days 21-30

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Hospital Choice:
  • Unlimited
  • Non-DSP use for PMBs: 30% co-payment. (DSP is any Netcare of Life healthcare)
Specialised Radiology:
  • MRI and CT scans: R14,700 per family with R1,480 co-payment, in and out of hospital. Not covered if for investigative purposes only.
  • PET scans: no benefit
Supplementary Services: (Physio, etc)
  • 100% scheme rate
Transplants:
  • Unlimited, subject to use of DSP
Co-payments:
  • Sigmoidoscopy and Cystoscopy: R2,100 co-payment in hospital
  • Hysteroscopy: R2,950 co-payment
  • Arthroscopy and Laparoscopy: R3,700 co-payment
  • Specialised radiology: R1,480 co-payment
  • Gap covers co-payments for most scopes and a defined list of other procedures, incl MRIs etc See full list
Alternatives to hospitals:
  • Hospice, private nursing, rehab, step-down and wound care: PMB only
Casualty:
  • Emergencies: scheme pays full account, including for dental emergencies.
Other:
  • Varicose vein surgery, facet joint injections, hysterectomy, rhizotomy, reflux surgery, back and neck surgery, joint replacement: PMB only
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OUT OF HOSPITAL BENEFITS:
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2017 v 2018 benefits Gap benefits Notes
GP consultations:
  • Paid from day-to-day benefit


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Childcare:
  • Peadiatrician: 2 consults in baby's first year, paid by scheme
  • non-PMBs chronic: medicine for Acne, ADD/ADHD, Rhinitis for children under age of 21, with 10% co-payment. Paid by scheme.
  • No benefit
Specialists consultations:
  • Paid from day-to-day benefit
Pathology:
  • Paid from day-to-day benefit
General radiology:
  • Paid from day-to-day benefit
Specialised radiology:
  • MRI and CT scans: R14,700 per family with R1,480 co-payment, in and out of hospital. Not if for investigative purposes only.
  • PET scans: No benefit
Supplementary Services: (Physio, etc)
  • Paid from day-to-day benefit
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MATERNITY BENEFITS:
Equilibrium
2017 v 2018 benefits Gap benefits Notes
Hospital stay:
  • Private ward for 3 days for natural birth

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Consultations:
  • 12 consults, paid by scheme
  • R1,060 for any shortfalls
  • Vitamins: R1,790 per pregnancy
  • Antenatal classes: R1,790 for first pregnancies
Scans:
  • 2 x 2D scans, paid by scheme
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CANCER (ONCOLOGY):
Equilibrium
2017 v 2018 benefits Gap benefits Notes
Overall coverage (in and out of hospital):
  • R139,500 per family, subject to use of DSP and scheme protocols
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.
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DENTISTRY:
Equilibrium
2017 v 2018 benefits Gap benefits Notes
Dentistry:
  • Standard dentistry: paid by scheme. Includes plastic dentures every 4 years
  • Specialised dentistry: no benefit
  • Hospitalisation: R1,480 co-payment. For young children and removal of wisdom teeth.

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Orthodontics:
  • No benefit
Maxillo Facial Surgery:
  • Subject to protocols

Avoid bills! Get up to: 800% scheme rate;  R12,800 per ER visit; unlimited cancer cover;  

co-payments paid and cash payout for hospital stay. R350pm per family

MEDICATION:
Equilibrium
2017 v 2018 benefits Gap benefits Notes
Chronic:
  • PMBs chronic: paid by scheme. 30% co-payment for non-DSP use
  • non-PMBs chronic: additional 3 conditions for children under 21 (Acne, ADD/ADHD, Rhinitis), 10% co-payment

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Acute (presrcibed) medication:
  • Paid from day-to-day benefit
Over-the-counter:
  • Paid from day-to-day benefit
Birth Control:
  • Meds: Paid from day-to-day benefit
  • Devices: paid from medical appliances benefit (R6,550 per family)
On Discharge:
  • R475
Biological:
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OPTOMETRY:
Equilibrium
2017 v 2018 benefits Gap benefits Notes
Optometry:
  • Paid from day-to-day benefit

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MENTAL HEALTH:
Equilibrium
2017 v 2018 benefits Gap benefits Notes
In-hospital:
  • Psychiatric: R17,700 per family in hospital

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Out-of-hospital:
  • Psychiatric: R17,700 per family in hospital
  • Out of hospital: PMB only
Trauma:
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OTHER BENEFITS:
Equilibrium
2017 v 2018 benefits Gap benefits Notes
General Appliances:
  • R6,550 per family, in and out of hospital
  • No benefit

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1.1. Hearing Aids:
  • No benefit
  • No benefit
1.2. Wheelchairs:
  • See "General Appliances" limit
  • No benefit
Dialysis:
  • PMB only
HIV:
  • Unlimited
  • Since HIV is a PMB certain out-of-hospital benefits are automatically covered by all schemes according to protocols
  • No benefit
Emergency Transport:
  • No benefit
International Insurance: 2018 benefits are coming soon!
  • No benefit
Other: 2018 benefits are coming soon!
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WELLNESS/PREVENTATIVE BENEFITS:
Equilibrium
2017 v 2018 benefits Gap benefits Notes
Flu vaccination:
  • Covered
  • No benefit

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Pneumonia vaccines:
  • Covered
  • No benefit
Back Rehabilitation Programme: 2018 benefits are coming soon!
  • No benefit
Biometric Screening:
  • Covered
  • No benefit
Child Immunisation:
  • Covered
  • No benefit
Pap Smear:
  • Covered, 15yrs+
  • No benefit
Mammogram:
  • Covered, 40yrs+ every two years
  • No benefit
PAS Test:
  • Covered, 40yrs+
  • No benefit
HIV Test:
  • Covered
  • , 15yrs+
  • No benefit
Other:
  • Tetanus injection
  • Malaria medication (R340)
  • HPV vaccination, age 9-14yrs
  • Weight loss programme for BMI over 30
  • No benefit

Avoid bills! Get up to: 800% scheme rate;  R12,800 per ER visit; unlimited cancer cover;  

co-payments paid and cash payout for hospital stay. R350pm per family

2017 v 2018 benefits Gap benefits Notes
Overal Limit:
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Sub-limits:
  • PMB only

    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