Keyhealth Essence medical aid plan: 2017 vs 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:
Essence
2018 costs In brief:
What’s new in 2018?
Main: Adult: Child:
Cost 2018: R1,360 R1,090 R490
Cost 2017: (R1,278) (R1,013) (R427)
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: No savings option on this plan
Children: Pay for all 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:
Essence
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:
  • Netcare or Life or State
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:
Essence
2017 v 2018 benefits Gap benefits Notes
GP consultations:
  • No benefit, unless PMB


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Childcare:
  • No benefit
Specialists consultations:
  • No benefit, unless PMB
Pathology:
  • No benefit, unless PMB
General radiology:
  • No benefit, unless PMB
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)
  • No benefit, unless PMB
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MATERNITY BENEFITS:
Essence
2017 v 2018 benefits Gap benefits Notes
Hospital stay:
  • 100% scheme rate

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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):
Essence
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:
Essence
2017 v 2018 benefits Gap benefits Notes
Dentistry:
  • One consult per person, , otherwise no benefit

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Orthodontics:
  • No benefit
Maxillo Facial Surgery:
  • PMBs only

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:
Essence
2017 v 2018 benefits Gap benefits Notes
Chronic:
  • PMBs chronic: paid by scheme. 30% co-payment for non-DSP use

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Acute (presrcibed) medication:
  • No benefit
Over-the-counter:
  • No benefit
Birth Control:
  • No benefit
On Discharge:
  • R475
Biological:
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OPTOMETRY:
Essence
2017 v 2018 benefits Gap benefits Notes
Optometry:
  • No benefit

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MENTAL HEALTH:
Essence
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:
Essence
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:
Essence
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)
  • 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