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KEYHEALTH EQUILIBRIUM 2019

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Medical Aid Year: 
2019
In Hospital Benefits
Hospital Rate of Payment: 
Unlimited, up to 100% of Agreed Tariff, subject to use of DSP hospital (Netcare or Life Healthcare). (30% co-payment at non-DSP hospital).
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).

State hospitals Unlimited, up to 100% of Agreed Tariff.

Specialists: 
Unlimited, subject to use of DSP provider.
Other healthcare professionals eg. Physio, Occupational, Dietician: 
Principal member: R7 245 p.a. Adult dependant: R5 265 p.a. Child dependant: R1 460 p.a.
Radiology and pathology: 
Pre-authorisation: specialised radiology, including MRI, CT and PET scans. Hospitalisation not covered if radiology is for investigative purposes only. (Day-to-day benefits will then apply.)
MRI and CT scans: 
R15 500 Pfpa. R1 560 co-payment per scan (in- or out-of-hospital), excluding confirmed PMBs.
Dialysis: 
Pre-authorisation compulsory and subject to Case Management and Scheme Protocols. PMB entitlement only.
Organ Transplants: 
Pre-authorisation compulsory and subject to Case Management. PMB entitlement in DSP hospitals only.
Oncology / Cancer: 
R165 000 Pfpa. Pre-authorisation compulsory and subject to Case Management and Scheme Protocols.
Neck and Back Operations: 
PMB entitlement only for varicose vein surgery and reflux surgery. The other procedures will be covered at 100% of Agreed Tariff.
Joint Replacements: 
PMB entitlement only for varicose vein surgery and reflux surgery. The other procedures will be covered at 100% of Agreed Tariff.
Prosthesis: 

R6 000 Pfpa. Pre-authorisation compusory and subject to Case Management,

reference pricing, DSP and Scheme Protocols.

Medical and Surgical Appliances: 
R7 100 Pfpa. Combined in- and out-of-hospital benefit, subject to quantities and protocols. No pre-authorisation required.
In Hospital Dentistry: 
Subject to DENIS protocols, Managed Care interventions and Scheme Rules. Exclusions apply in accordance with Scheme Rules.
Take home Medicine: 
R500 Per admission.
Rehabilitation, Hospice and Step-down facilities: 
R28 000 Pre-authorisation compulsory and subject to Case Management and Scheme Protocols. Pfpa. Wound care is included in this benefit, up to an amount of R9 000. Combined in- and out-of-hospital benefit.
Treatment for Mental Health: 
R18 700 Pfpa. Pre-authorisation compulsory and subject to Case Management. In-hospital benefit only. Out-of-hospital: PMB entitlement.
HIV / AIDS: 
Unlimited. Chronic Disease Programme, managed by Lifesense, applicable.
Day-to-day benefits
GP consultations: 

Principal member: R7 245 p.a.
Adult dependant: R5 265 p.a.
Child dependant: R1 460 p.a.

Specialist consultations: 

Principal member: R7 245 p.a.
Adult dependant: R5 265 p.a.
Child dependant: R1 460 p.a.

Over-the-counter (OTC) Medicine: 

R1 560 Pfpa sublimit. Subject to day-to-day benefit.

Optometry benefits: 
R1 470 Pbp2a total optical benefit. Subject to day-to-day benefit and Optical Management. Benefit confirmation compulsory.
Basic dentistry: 
DENIS protocols, Scheme Rules and Managed Care interventions apply. Exclusions apply in accordance with Scheme Rules. Consultations 100% 2 check-ups pbpa.
Specialised Dentistry: 
No benefit.
Orthodontics: 

Orthodontics (non-cosmetic treatment only) 80% DENIS pre-authorisation compulsory. Subject to Denis protocols, Managed Care
interventions and Scheme Rules. Exclusions apply in terms of Scheme Rules.

MRI and CT Scans (Out of Hospital): 
R15 500 Pfpa. R1 560 co-payment per scan (in- or out-of-hospital), excluding confirmed PMBs.
Radiology and Pathology: 
Pre-authorisation: specialised radiology, including MRI, CT and PET scans. Hospitalisation not covered if radiology is for investigative purposes only. (Day-to-day benefits will then apply.)
Pregnancy benefits: 
Antenatal visits (GP, Gynaecologist or midwife) & urine test (dipstick)# Female beneficiaries. Pre-notification of and pre-authorisation by the Scheme compulsory. 12 visits. Ultrasounds (GP or Gynaecologist) – one before the 24th week and one thereafter
Chronic Conditions
Chronic Conditions: 

Category A (CDL) 100% Unlimited – subject to reference pricing and protocols.
Registration on Chronic Disease Programme compulsory.
Category B (other) 90% Additional 3 non-PMB/CDL conditions (Acne/ADHD or ADD/Rhinitis) for

children up to the age of 21.

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 – R360 once per year.
HPV vaccination Female beneficiaries aged ≤9-14
– 2 doses per lifetime.

Baby growth assessments

3 baby growth assessments at a
pharmacy/baby clinic for beneficiaries
aged between 0 – 35 months – per year.

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: 
2033.00
Total Contribution Adult: 
1255.00
Total Contribution Child*: 
623.00
Equilibrium
Monthly Medical Savings
Savings Child*: 
97.00
Savings Adult: 
334.00
Savings Main Member: 
494.00
Risk Contributions
Risk Contribution Main Member: 
1885.00
Risk Contribution Adult: 
1164.00
Risk Contribution Child: 
578.00
Medical Aid Plan Name Term: 
Any