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KeyHealth Medical Scheme - ESSENCE 2018

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

No benefit.

Co-payments: 
Sigmoidoscopy and cystoscopy: R2100. Hysteroscopy: R2950. Arthroscopy and laparoscopy: R3700. Scans R1 480 co-payment per scan (in- or out-of-hospital)
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).

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: 
No benefit.
In Hospital Dentistry: 
No benefit.
Take home Medicine: 
475 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: 

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): 
R14 700 Per family per year R1 480 co-payment per scan (in- or out-of-hospital), excluding confirmed PMBs.
Radiology and Pathology: 
100% of Scheme Rate Pathology PMB entitlement 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
Physiotherapy and Occupational Therapy day to day: 
No 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: 
No benefit.
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: 
1360.00
Total Contribution Adult: 
1090.00
Total Contribution Child*: 
490.00
ESSENCE OPTION
Monthly Medical Savings
Savings Child*: 
0.00
Savings Adult: 
0.00
Savings Main Member: 
0.00
Risk Contributions
Risk Contribution Main Member: 
1360.00
Risk Contribution Adult: 
1090.00
Risk Contribution Child: 
490.00
Principal Member Risk: 
1360.00
Principal Member Savings: 
0.00
Principal Member Total: 
1360.00
Per Adult Dependent Risk: 
1090.00
Per Adult Dependent Savings: 
0.00
Per Adult Dependent Total: 
1090.00
Child dependant Risk: 
490.00
Child dependant Savings: 
0.00
Child dependant Total: 
490.00
How many times per annum do you and your dependants visit a doctor?: 
0
How much do you spend on Acute medication per annum?: 
0
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