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KeyHealth Medical Scheme - EQUILIBRIUM 2018

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Type of Medical Aid Plan: 
Hybrid
Medical Aid Year: 
2018
Day to day Benefits: 

Routine medical expenses like, General practitioner and specialist consultations, radiology (incl. Nucleur Medicine Study and bone density scans). Prescribed and over-the-counter medicine. Optical and auxiliary services, e.g. physiotherapy, occupational therapy, contraceptive pills and biokinetics. This is a family benefit which means that one member of the family can use the total benefit allocation.

PM - R1 692 pa

AD - R1 044 pa

CD - R516 pa

Additional day-to-day benefits:  PM - R2558 pa, AD - R1756 pa, CD - R784 pa

Co-payments: 
Sigmoidoscopy and cystoscopy: R2100. Hysteroscopy: R2950. Arthroscopy and laparoscopy: R3700. R1480 co-payment per scan (in- or out of hospital). Dentistry R1480 per admission.
In Hospital Benefits
Are you prepared to use designated hospitals?: 
Yes
Hospital Rate of Payment: 
100% of Scheme Rate
Hospitals: 

Private hospitals. Unlimited, up to 100% of Agreed Tariff, subject to use of DSP hospital (Netcare or Life Healthcare).

(30% co-payment at non-DSP hospital.)

Upfront Payments to hospitals: 

Sigmoidoscopy and cystoscopy: R2100.

Hysteroscopy: R2950.

Arthroscopy and laparoscopy: R3700. R1480 co-payment per scan (in- or out of hospital).

Dentistry R1480 per admission.

Casualty / Emergency Visits: 
Easy ER available no upfront payment required
Specialists: 
100% Unlimited, subject to use of DSP provider.
Other healthcare professionals eg. Physio, Occupational, Dietician: 
100% of Scheme Rate
Radiology and pathology: 
100% of Scheme Rate
Scopes (gastroscopy, colonoscopy, sigmoidoscopy and proctoscopy): 
Colonoscopy and/or gastroscopy. Pre-authorisation compulsory. No co-payment at DSP hospital, out-of-hospital and PMB. Other, in-hospital co-payments per scope: Sigmoidoscopy and cystoscopy: R2100. Hysteroscopy: R2950. Arthroscopy and laparoscopy: R3700.
MRI and CT scans: 
R14 700 Per family per year. R1 480 co-payment per scan (in- or out-of-hospital), excluding confirmed PMBs.
ICU and High Care: 
100% of Scheme Rate
Dialysis: 
Pre-authorisation compulsory and subject to Case Management and Scheme Protocols. PMB entitlement only.
Organ Transplants: 
Solid organs, tissue and corneas Hospitalisation, harvesting and drugs for immuno-suppressive therapy. 100% Pre-authorisation compulsory and subject to Case Management. PMB entitlement in DSP hospitals only.
Oncology / Cancer: 
R139 500 per family per annum. Pre-authorisation compulsory and subject to case management and Scheme Protocols.
Neck and Back Operations: 
PMB entitlement only.
Joint Replacements: 
PMB entitlement only.
Prosthesis: 

Prosthetics / Prosthesis (Internal, external, fixation devices and implanted devices). 100%.

Subject to pre-authorisation and Scheme Protocols. PMB entitlement only.

Medical and Surgical Appliances: 
Wheelchairs, orthopaedic appliances and incontinence equipment (incl. contraceptive devices) 100% & R6 550 Per family per annum. Combined in- and out-of-hospital benefit, subject to quantities and protocols. No pre-authorisation required.
Maternity Confinements: 
Private ward for 3 days for natural birth.
In Hospital Dentistry: 
R1 480 co-payment per hospital admission. DENIS pre-authorisation compulsory. Removal of impacted wisdom teeth and for children under the age of 5 years for extensive dental treatment
Take home Medicine: 
R475 Per admission.
Rehabilitation, Hospice and Step-down facilities: 
Hospice, private nursing, rehabilitation, step-down facilities and wound care. 100%. Pre-authorisation compulsory and subject to Case Management and Scheme Protocols. PMB entitlement only.
Treatment for Mental Health: 
R17 700 per family per annum. Pre-authorisation compulsory and subject to Case Management.In-hospital benefit only. Out-of-hospital: PMB entitlement.
HIV / AIDS: 
100% & Unlimited. Chronic Disease Management programme applicable.
Ambulance Service: 
100%. DSP(Designated Service Provider) - NETCARE 911. Unlimited, subject to use of DSP and protocols. (40% co-payment at non-DSP service provider.)
International Travel Benefit: 
No benefit.
Day-to-day benefits
GP consultations: 

A combined out-of-hospital limit which may be used by any beneficiary in respect of general practitioners, specialists, radiology, optical, pathology, prescribed medicine and auxiliary services, and which may include a sub-limit for self-medication.

Annual Medical Savings Account (MSA):

PM: R1 692 p.a.

AD: R1 044 p.a.

CD: R516 p.a.

Additional day-to-day benefits:

PM: R2 558 p.a.

AD: R1 756 p.a.

CD: R784 p.a.

Specialist consultations: 

A combined out-of-hospital limit which may be used by any beneficiary in respect of general practitioners, specialists, radiology, optical, pathology, prescribed medicine and auxiliary services, and which may include a sub-limit for self-medication.

Annual Medical Savings Account (MSA):

PM: R1 692 p.a.

AD: R1 044 p.a.

CD: R516 p.a.

Additional day-to-day benefits:

PM: R2 558 p.a.

AD: R1 756 p.a.

CD: R784 p.a.

Acute medicine: 

Subject to MSA / day-to-day benefit.

Over-the-counter (OTC) Medicine: 

Subject to MSA / day-to-day benefit.

Over-the-counter reading glasses. R100. Per beneficiary per annum (per year). 1 pair per year. Subject to MSA / day-to-day benefit.

Optometry benefits: 
100% Optical Management applicable. Benefit confirmation compulsory.
Basic dentistry: 
Subject to DENIS protocols, Managed Care interventions and Scheme Rules. Exclusions apply in accordance with Scheme Rules. 100% Consultations, X-rays: Intra & Extra-oral, Oral hygiene, Fillings, Tooth extractions, Root canal treatment & Plastic dentures
Specialised Dentistry: 
No benefit. Subject to MSA.
Orthodontics: 

No benefit. Subject to MSA.

MRI and CT Scans (Out of Hospital): 
R14 700. Per family per annum (per year). R1 480 co-payment per scan (in- or out-of-hospital), excluding confirmed PMBs.
Radiology and Pathology: 
Subject to MSA / day-to-day benefit.
Pregnancy benefits: 
12 Antenatal visits, 2 Ultrasounds (GP, Gynaecologist or midwife), urine test. Pre-notification of and pre-authorisation by the Scheme compulsory. Short payments/co-payments for services & birthing fees. 2 Paediatrician visits. Ante-natal vitamins & class
Physiotherapy and Occupational Therapy day to day: 
Subject to MSA / day-to-day benefit.
Chronic Conditions
Provider: 
Designated Service Provider
Chronic Conditions: 

Category A (CDL) 100% & Unlimited – subject to reference pricing and protocols.

Registration on Chronic Disease Programme compulsary. (30% co-payment at non-DSP pharmacy.)

Additional Chronic Conditions: 
Category B (other) 90%. Additional 3 non-PMB/CDL conditions (Acne/ADHD or ADD/Rhinitis) for children up to the age of 21. 10% co-payment applicable when using a non-DSP pharmacy. (Co-payment payable directly to the service provider involved.)
Preventative Care Benefits
Preventative Benefits: 

PREVENTIVE CARE

Baby immunisation. Child dependants aged ≤6 – as required by the Department of Health.

Flu vaccination. All beneficiaries.

Tetanus diphtheria injection. All beneficiaries – as and when required.

Pneumococcal vaccination. All beneficiaries.

Malaria medication. All beneficiaries – R340 once per year.

HPV vaccination. Female beneficiaries aged ≤9-14 – 2 doses per lifetime.

EARLY DETECTION TESTS

Pap smear (Pathologist). Female beneficiaries aged ≥15 – once per year.

Pap smear (including consultation and pelvic organs ultrasound; GP or Gynaecologist). Female beneficiaries aged ≥15– once per year.

Mammogram. Female beneficiaries aged ≥40 – once per year.

Prostate specific antigen (PSA) (Pathologist). Male beneficiaries aged ≥40 – once per year.

HIV/AIDS test (Pathologist). Beneficiaries aged ≥15 – once per year.

Health Assessment (HA): Body mass index, Blood pressure measurement, Cholesterol test (finger prick), Blood sugar test (finger prick) PSA (finger prick). Adult beneficiaries – once per year.

Total Contributions
Total Contribution Main Member: 
1936.00
Total Contribution Adult: 
1195.00
Total Contribution Child*: 
593.00
EQUILIBRIUM OPTION
Annual Medical Savings Account
Annual Medical Savings Main Member: 
1692.00
Annual Medical Savings Adult: 
1044.00
Annual Medical Savings Child*: 
516.00
Monthly Medical Savings
Savings Child*: 
43.00
Savings Adult: 
87.00
Savings Main Member: 
141.00
Risk Contributions
Risk Contribution Main Member: 
1795.00
Risk Contribution Adult: 
1108.00
Risk Contribution Child: 
550.00
Principal Member Risk: 
1795.00
Principal Member Savings: 
141.00
Principal Member Total: 
1936.00
Per Adult Dependent Risk: 
1108.00
Per Adult Dependent Savings: 
87.00
Per Adult Dependent Total: 
1195.00
Child dependant Risk: 
550.00
Child dependant Savings: 
43.00
Child dependant Total: 
593.00
How many times per annum do you and your dependants visit a doctor?: 
5
How much do you spend on Acute medication per annum?: 
R1000 - R4999
How much do you spend on Chronic medication per annum?: 
More than R 5000
Will you or any of your dependants require specialised Dentistry: 
No