Keyhealth Essence medical aid plan: 2017

Out-of-hospital, scheme pays for some: specialised radiology (co-payment), maternity, medical appliances, oncology, preventative benefits. Limits apply. All else paid from out of pocket, unless PMB. Pay for all children.

View all plans in this scheme

IN HOSPITAL PROCEDURES:
Payout Rate for Specialists:
Overall Annual Limit (OAL):
Unlimited overall, with sub-limits
Contributions:
Main: Adult: Child:
Total Cost: R1,278 R1,013 R427
Children: Pay for all children
Day-to-Day Benefit:
Out-of-hospital, scheme pays for some: specialised radiology (co-payment), maternity, medical appliances, oncology, preventative benefits. Limits apply. All else paid from out of pocket, unless PMB.
Main: Adult: Child:
(S) Savings: R0- R0- R0-

Compare with these plans:
Hospital Choice:
  • Netcare or Life or State
Specialised Radiology:
  • MRI and CT scans: R13,900 per family with R1,400 co-payment, in and out of hospital
  • PET scans: No benefit
Supplementary Services: (Physio, etc)
Transplants:
  • Unlimited, subject to use of DSP
Co-payments:
  • Sigmoidoscopy and Cystoscopy: R2,000 co-payment in hospital
  • Hysteroscopy: R2,800 co-payment
  • Arthroscopy and Laparoscopy: R3,500 co-payment
  • Specialised radiology: R1,400 co-payment
Alternatives to hospitals:
  • Hospice, private nursing, rehab, step-down and wound care: PMB only

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OUT OF HOSPITAL BENEFITS:
GP consultations:
  • No benefit
Overall Annual Limit (OAL):
Unlimited overall, with sub-limits
Contributions:
Main: Adult: Child:
Total Cost: R1,278 R1,013 R427
Children: Pay for all children
Day-to-Day Benefit:
Out-of-hospital, scheme pays for some: specialised radiology (co-payment), maternity, medical appliances, oncology, preventative benefits. Limits apply. All else paid from out of pocket, unless PMB.
Main: Adult: Child:
(S) Savings: R0- R0- R0-

Compare with these plans:

Specialists consultations:
  • No benefit, unless PMB
Pathology:
  • No benefit, unless PMB
General radiology:
  • No benefit, unless PMB
Specialised radiology:
  • MRI and CT scans: R13,900 per family with R1,400 co-payment, in and out of hospital
  • PET scans: No benefit
Supplementary Services: (Physio, etc)
  • No benefit, unless PMB

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MATERNITY BENEFITS:
Hospital stay:
Overall Annual Limit (OAL):
Unlimited overall, with sub-limits
Contributions:
Main: Adult: Child:
Total Cost: R1,278 R1,013 R427
Children: Pay for all children
Day-to-Day Benefit:
Out-of-hospital, scheme pays for some: specialised radiology (co-payment), maternity, medical appliances, oncology, preventative benefits. Limits apply. All else paid from out of pocket, unless PMB.
Main: Adult: Child:
(S) Savings: R0- R0- R0-

Compare with these plans:

Consultations:
  • 12 consults, paid by scheme
  • Vitamins: R1,690 per pregnancy
  • Antenatal classes: R1,690 for first pregnancies
Scans:
  • 2 x 2D scans, paid by scheme

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CANCER (ONCOLOGY):
Overall coverage (in and out of hospital):
  • R131,500 per family, subject to use of DSP and scheme protocols

Note: 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.
Overall Annual Limit (OAL):
Unlimited overall, with sub-limits
Contributions:
Main: Adult: Child:
Total Cost: R1,278 R1,013 R427
Children: Pay for all children
Day-to-Day Benefit:
Out-of-hospital, scheme pays for some: specialised radiology (co-payment), maternity, medical appliances, oncology, preventative benefits. Limits apply. All else paid from out of pocket, unless PMB.
Main: Adult: Child:
(S) Savings: R0- R0- R0-

Compare with these plans:

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DENTISTRY:
Dentistry:
  • No benefit, unless PMBs
Overall Annual Limit (OAL):
Unlimited overall, with sub-limits
Contributions:
Main: Adult: Child:
Total Cost: R1,278 R1,013 R427
Children: Pay for all children
Day-to-Day Benefit:
Out-of-hospital, scheme pays for some: specialised radiology (co-payment), maternity, medical appliances, oncology, preventative benefits. Limits apply. All else paid from out of pocket, unless PMB.
Main: Adult: Child:
(S) Savings: R0- R0- R0-

Compare with these plans:

Orthodontics:
  • No benefit
Maxillo Facial Surgery:

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MEDICATION:
Chronic:
  • PMBs chronic: paid by scheme
Overall Annual Limit (OAL):
Unlimited overall, with sub-limits
Contributions:
Main: Adult: Child:
Total Cost: R1,278 R1,013 R427
Children: Pay for all children
Day-to-Day Benefit:
Out-of-hospital, scheme pays for some: specialised radiology (co-payment), maternity, medical appliances, oncology, preventative benefits. Limits apply. All else paid from out of pocket, unless PMB.
Main: Adult: Child:
(S) Savings: R0- R0- R0-

Compare with these plans:
Acute (presrcibed) medication:
  • No benefit
Over-the-counter:
  • No benefit
Birth Control:
  • No benefit
On Discharge:
  • R450
Notes:
  • Chronic medicine: 30% co-payment where non-DSP pharmacy is used
  • Reference pricing

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OPTOMETRY:
Optometry:
  • No benefit
Overall Annual Limit (OAL):
Unlimited overall, with sub-limits
Contributions:
Main: Adult: Child:
Total Cost: R1,278 R1,013 R427
Children: Pay for all children
Day-to-Day Benefit:
Out-of-hospital, scheme pays for some: specialised radiology (co-payment), maternity, medical appliances, oncology, preventative benefits. Limits apply. All else paid from out of pocket, unless PMB.
Main: Adult: Child:
(S) Savings: R0- R0- R0-

Compare with these plans:

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MENTAL HEALTH:
In-hospital:
  • Psychiatric: R16,700 per family in hospital
Overall Annual Limit (OAL):
Unlimited overall, with sub-limits
Contributions:
Main: Adult: Child:
Total Cost: R1,278 R1,013 R427
Children: Pay for all children
Day-to-Day Benefit:
Out-of-hospital, scheme pays for some: specialised radiology (co-payment), maternity, medical appliances, oncology, preventative benefits. Limits apply. All else paid from out of pocket, unless PMB.
Main: Adult: Child:
(S) Savings: R0- R0- R0-

Compare with these plans:


Out-of-hospital:
  • Psychiatric: R16,700 per family in hospital
  • Out of hospital: PMB only

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OTHER BENEFITS:
General Appliances:
  • R6,200 per family, in and out of hospital
Overall Annual Limit (OAL):
Unlimited overall, with sub-limits
Contributions:
Main: Adult: Child:
Total Cost: R1,278 R1,013 R427
Children: Pay for all children
Day-to-Day Benefit:
Out-of-hospital, scheme pays for some: specialised radiology (co-payment), maternity, medical appliances, oncology, preventative benefits. Limits apply. All else paid from out of pocket, unless PMB.
Main: Adult: Child:
(S) Savings: R0- R0- R0-

Compare with these plans:

1.1. Hearing Aids:
  • No benefit
1.2. Wheelchairs:
  • See "General Appliances" limit
Dialysis:
  • PMB only
HIV:
  • Unlimited
  • Since HIV is a PMB certain out-of-hospital benefits are automatically covered by all schemes according to protocols
Emergency Transport: Netcare911
International Coverage:
Other:

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WELLNESS/PREVENTATIVE BENEFITS:
Flu vaccination:
  • Covered
Overall Annual Limit (OAL):
Unlimited overall, with sub-limits
Contributions:
Main: Adult: Child:
Total Cost: R1,278 R1,013 R427
Children: Pay for all children
Day-to-Day Benefit:
Out-of-hospital, scheme pays for some: specialised radiology (co-payment), maternity, medical appliances, oncology, preventative benefits. Limits apply. All else paid from out of pocket, unless PMB.
Main: Adult: Child:
(S) Savings: R0- R0- R0-

Compare with these plans:

Pneumonia vaccines:
  • Covered
Back Rehabilitation Programme:
Biometric Screening:
  • Covered
Child Immunisation:
  • Covered
Pap Smear:
  • Covered, 15yrs+
Mammogram:
  • Covered, 40yrs+ every two years
PAS Test:
  • Covered, 40yrs+
HIV Test:
  • Covered
    • , 15yrs+

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PROSTHESIS:
Overal Limit:
Overall Annual Limit (OAL):
Unlimited overall, with sub-limits
Contributions:
Main: Adult: Child:
Total Cost: R1,278 R1,013 R427
Children: Pay for all children
Day-to-Day Benefit:
Out-of-hospital, scheme pays for some: specialised radiology (co-payment), maternity, medical appliances, oncology, preventative benefits. Limits apply. All else paid from out of pocket, unless PMB.
Main: Adult: Child:
(S) Savings: R0- R0- R0-

Compare with these plans:
Sub-limits:

    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