Keyhealth Equillibrium medical aid plan: 2018

View all plans in this scheme.
Please note that these benefits are still being updated as more information is made available to us. Always consult with your broker before making final decisions regarding your healthcare cover.

COSTS and OVERVIEW:
Equilibrium
Quick Overview
Main: Adult: Child:
Total Cost pm: R1,936 R1,195 R593

(Pay only for first 3)

Savings: R1,692 R1,044 R516
Extended Fund: R2,558 R1,756 R784
Gap (optional):
  • Varies. See below for specific recommendation for this plan.
In brief: See full benefits below

IN HOSPITAL PROCEDURES:
Equilibrium
Scheme Benefits: Gap Benefits:
Specialists:
  • 100% scheme rate
  • You or gap cover pay the balance, if any
  • Gap tops this up to 500% scheme rate for in-hospital specialists, GPs and other medical professionals
  • Recommended for this plan: Plan Blue, R295pm per family where no member is older than 64yrs (otherwise, R435pm per family)
Hospital Choice:
  • Choose any hospital
  • Non-DSP use for PMBs: 30% co-payment. (DSP is any Netcare or Life facility)
  • No benefit
Specialised Radiology:
  • MRI and CT scans: R14,700 per family with R1,480 co-payment, in and out of hospital. Not covered if for investigative purposes only.
  • PET scans: no benefit
  • Co-payment paid
  • Sublimit increased as necessary, for approved procedures
  • No benefit for exclusions
Supplementary Services: (Physio, etc)
  • 100% scheme rate
  • Gap tops this up to 500% scheme rate for in-hospital specialists, GPs and other medical professionals, for non-PMB treatment
Transplants:
  • Covered, subject to use of DSP
  • No extra benefit available (PMB benefits are paid in full by medical aid)
Co-payments:
  • Sigmoidoscopy and Cystoscopy: R2,100 co-payment in hospital
  • Hysteroscopy: R2,950 co-payment
  • Arthroscopy and Laparoscopy: R3,700 co-payment
  • Specialised radiology: R1,480 co-payment
  • Co-payments paid by you or your gap cover
  • Gap cover pays co-payments for procedures approved by medical aid
Alternatives to hospitals:
  • Hospice, private nursing, rehab, step-down and wound care: PMB only
  • No benefit
Casualty:
  • Emergencies: scheme pays full account, including for dental emergencies.
  • Pays up to R20,000 per person per year for emergency medical treatment not paid for by medical aid
Other:
  • Varicose vein surgery, facet joint injections, hysterectomy, rhizotomy, reflux surgery, back and neck surgery, joint replacement: PMB only
  • No benefit
Note:
  • Gap cover is an add-on to your medical aid, not a stand alone product
  • Gap cover has a maximum benefit payout of R150,000 per person per year for all gap benefits (except dread disease and premium waiver benefits which do not count towards the R150,000 limit)
  • Gap only supplements payment for procedures approved or authorised by your medical aid, and does not cover “penalties” (such as if, for example, you choose a non-DSP doctor for your procedure when the plan required a DSP doctor)

No phone calls!
Our quote will include the right gap cover for this plan

All benefits, including gap benefits, are subject to treatments and procedures being authorised by medical scheme.
The gap benefits listed are for AskAdam gaps, unless otherwise stated. Actual benefits depend on gap choice option.

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OUT OF HOSPITAL BENEFITS (non-PMB):
Equilibrium
Scheme Benefits Gap benefits
Main: Adult: Child:
Savings /yr: R1,692 R1,044 R516
Extended Fund: R2,558 R1,756 R784
General info:
  • Our recommended gap cover does not pay out-of-hospital claims, unless it is for cancer treatment, dialysis, or MRI/CT scans
GP consultations:
  • Paid from day-to-day benefit
Childcare:
  • Peadiatrician: 2 consults in baby's first year, paid by scheme
  • non-PMBs chronic: medicine for Acne, ADD/ADHD, Rhinitis for children under age of 21, with 10% co-payment. Paid by scheme.
  • No extra benefit available
Specialists consultations:
  • Paid from day-to-day benefit
Pathology:
  • Paid from day-to-day benefit
General radiology:
  • Paid from day-to-day benefit
Specialised radiology:
  • MRI and CT scans: R14,700 per family with R1,480 co-payment, in and out of hospital. Not if for investigative purposes only.
  • PET scans: No benefit
Supplementary Services: (Physio, etc)
  • Paid from day-to-day benefit

No phone calls!
Our quote will include the right gap cover for this plan

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MATERNITY BENEFITS:
Equilibrium
Scheme Benefits Gap benefits
Hospital stay:
  • Private ward for 3 days for natural birth
  • Pays up to 500% scheme rate for specialists, GPs and other medical professionals, in-hospital only
Consultations:
  • 12 consults, paid by scheme
  • R1,060 for any shortfalls
  • Vitamins: R1,790 per pregnancy
  • Antenatal classes: R1,790 for first pregnancies
Scans:
  • 2 x 2D scans, paid by scheme

No phone calls!
Our quote will include the right gap cover for this plan

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CANCER (ONCOLOGY):
Equilibrium
Scheme Benefits Gap benefits
Overall coverage (in and out of hospital):
  • R139,500 per family, subject to use of DSP and scheme protocols
  • Once you or the medical scheme have spent R200,000 per oncology treatment cycle from a private hospital, your sublimits increase as necessary. More info

No phone calls!
Our quote will include the right gap cover for this plan

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DENTISTRY:
Equilibrium
Scheme Benefits Gap benefits
Dentistry:
  • Standard dentistry: paid by scheme. Includes plastic dentures every 4 years
  • Specialised dentistry: no benefit
  • Hospitalisation: R1,480 co-payment. For young children and removal of wisdom teeth.
  • Pays shortfalls and co-payments for in-hospital dentistry treatment approved by scheme
Orthodontics:
  • You pay this out of pocket
  • No extra benefit available
Maxillo Facial Surgery:
  • Subject to protocols
  • Pays shortfalls and co-payments for any non-PMB in-hospital dentistry treatment approved by scheme. (PMB are paid in full by scheme if you use DSP)

No phone calls!
Our quote will include the right gap cover for this plan

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MEDICATION:
Equilibrium
Scheme Benefits Gap benefits
Chronic:
  • PMBs chronic: paid by scheme. 30% co-payment for non-DSP use
  • non-PMBs chronic: additional 3 conditions for children under 21 (Acne, ADD/ADHD, Rhinitis), 10% co-payment
Acute (presrcibed) medication:
  • Paid from day-to-day benefit
Over-the-counter:
  • Paid from day-to-day benefit
Birth Control:
  • Meds: Paid from day-to-day benefit
  • Devices: paid from medical appliances benefit (R6,550 per family)
On Discharge:
  • R475
Biological:

No phone calls!
Our quote will include the right gap cover for this plan

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OPTOMETRY:
Equilibrium
Scheme Benefits Gap benefits
Optometry:
  • Paid from day-to-day benefit
  • Pays shortfalls and co-payments for any non-PMB in-hospital treatment approved by scheme. (PMBs are paid in full by scheme if you use DSP)

No phone calls!
Our quote will include the right gap cover for this plan

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MENTAL HEALTH:
Equilibrium
Scheme Benefits Gap benefits
In-hospital:
  • Psychiatric: R17,700 per family in hospital
  • No benefit
Out-of-hospital:
  • Psychiatric: R17,700 per family in hospital
  • Out of hospital: PMB only
  • No benefit
Trauma:
  • No benefit

No phone calls!
Our quote will include the right gap cover for this plan

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OTHER BENEFITS:
Equilibrium
Scheme Benefits Gap benefits
General Appliances:
  • R6,550 per family, in and out of hospital
  • No benefit
1.1. Hearing Aids:
  • No benefit
  • No benefit
1.2. Wheelchairs:
  • See "General Appliances" limit
  • No benefit
Dialysis:
  • PMB only
HIV:
  • Unlimited
  • Since HIV is a PMB certain out-of-hospital benefits are automatically covered by all schemes according to protocols
  • No benefit
Emergency Transport: Netcare911
  • No benefit
International Insurance: 2018 benefits are coming soon!
  • No benefit
Other: 2018 benefits are coming soon!
  • No benefit

No phone calls!
Our quote will include the right gap cover for this plan

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WELLNESS/PREVENTATIVE BENEFITS:
Equilibrium
Scheme Benefits Gap benefits
Flu vaccination:
  • Covered
  • No benefit
Pneumonia vaccines:
  • Covered
  • No benefit
Back Rehabilitation Programme: 2018 benefits are coming soon!
  • No benefit
Biometric Screening:
  • Covered
  • No benefit
Child Immunisation:
  • Covered
  • No benefit
Pap Smear:
  • Covered, 15yrs+
  • No benefit
Mammogram:
  • Covered, 40yrs+ every two years
  • No benefit
PAS Test:
  • Covered, 40yrs+
  • No benefit
HIV Test:
  • Covered
  • , 15yrs+
  • No benefit
Other:
  • Tetanus injection
  • Malaria medication (R340)
  • HPV vaccination, age 9-14yrs
  • Weight loss programme for BMI over 30
  • No benefit

No phone calls!
Our quote will include the right gap cover for this plan

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PROSTHETICS:
Equilibrium
Scheme Benefits Gap benefits
Overal Limit:
  • PMB only
  • Sublimit increased by up to R150,000 per person
  • No benefit for procedures excluded by medical aid
Sub-limits:
  • Sublimit increased by up to R150,000 per person
  • No benefit for procedures excluded by medical aid

No phone calls!
Our quote will include the right gap cover for this plan


    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