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KEYHEALTH ESSENCE 2019

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Type of Medical Aid Plan: 
Hospital
Medical Aid Year: 
2019
Day to day Benefits: 

No benefit

In Hospital Benefits
Hospital Rate of Payment: 
100% of Scheme Rate
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: 

R1 560 co-payment per scan (in- or out-of-hospital),

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): 
100% of Scheme Rate
MRI and CT scans: 
R15 500 P.A 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: 
R147 000 P.A Pfpa. Pre-authorisation compulsory and subject to Case Management and Scheme Protocols.
Neck and Back Operations: 
PMB entitlement only. Hysterectomies will be covered at 100% of Agreed Tariff.
Joint Replacements: 
PMB entitlement only. Hysterectomies will be covered at 100% of Agreed Tariff.
Prosthesis: 

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

Medical and Surgical Appliances: 
R6 900 P.A Pfpa. Combined in- and out-of-hospital benefit, subject to quantities and protocols. No pre-authorisation required.
Maternity Confinements: 
No benefit
In Hospital Dentistry: 
No benefit
Take home Medicine: 
R500 Per admission.
Rehabilitation, Hospice and Step-down facilities: 
Pre-authorisation compulsory and subject to Case Management and Scheme Protocols. PMB entitlement only.
Treatment for Mental Health: 
R18 700 P.A Pfpa. In-hospital services. Pre-authorisation compusory and subject to Case Management.
HIV / AIDS: 
Unlimited. Chronic Disease Programme, managed by Lifesense, applicable.
Ambulance Service: 
DSP – NETCARE 911. Unlimited, subject to use of DSP and protocols. (20% co-payment at non-DSP service provider.)
International Travel Benefit: 
No benefit.
Day-to-day benefits
GP consultations: 

No benefit. PMB entitlement only.

Specialist consultations: 

No benefit.

Acute medicine: 

No benefit.

Over-the-counter (OTC) Medicine: 

No benefit.

Optometry benefits: 
No benefit.
Basic dentistry: 
One consultation per beneficiary per year
Specialised Dentistry: 
No benefit.
Orthodontics: 

No benefit.

MRI and CT Scans (Out of Hospital): 
R15 500 P.A Pfpa. R1 560 co-payment per scan (in- or out-of-hospital), excluding confirmed PMBs.
Radiology and Pathology: 
Pre-authorisation compulsory for specialised radiology, including MRI and CT scans. Hospitalisation not covered if radiology is for investigative purposes only.
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
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.)

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: 
1456.00
Total Contribution Adult: 
1167.00
Total Contribution Child*: 
525.00
ESSENCE OPTION
Risk Contributions
Risk Contribution Main Member: 
1456.00
Risk Contribution Adult: 
1167.00
Risk Contribution Child: 
525.00
Medical Aid Plan Name Term: 
Any