Keyhealth Gold 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:
Gold
Quick Overview
Main: Adult: Child:
Total Cost pm: R4,516 R3,054 R885

(Pay for all)

Savings: R5,412 R3,660 R1,056
Extended Fund: R4,440 R3,310 R1,060
Gap (optional):
  • Varies. See below for specific recommendation for this plan.
In brief: See full benefits below

IN HOSPITAL PROCEDURES:
Gold
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: 2 scans per person. Maximum R16,300 per scan
  • 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:
  • Specialised radiology: R1,480 co-payment 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: R36,100 per family in and out of hospital
  • Wound care sublimit: R11,900
  • 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:
  • N/A
  • N/A
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.

.
.
.
.
OUT OF HOSPITAL BENEFITS (non-PMB):
Gold
Scheme Benefits Gap benefits
Main: Adult: Child:
Savings /yr: R5,412 R3,660 R1,056
Extended Fund: R4,440 R3,310 R1,060
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
  • No extra benefit available
Specialists consultations:
  • Paid from day-to-day benefit
Pathology:
  • 30% co-payment
  • 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: 2 scans per person. Maximum R16,300 per scan
Supplementary Services: (Physio, etc)
  • Paid from day-to-day benefit

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

.
.
MATERNITY BENEFITS:
Gold
Scheme Benefits Gap benefits
Hospital stay:
  • 100% scheme rate
  • Private ward for 3 day stay forr 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

.
.
CANCER (ONCOLOGY):
Gold
Scheme Benefits Gap benefits
Overall coverage (in and out of hospital):
  • R358,000 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

.
.
DENTISTRY:
Gold
Scheme Benefits Gap benefits
Dentistry:
  • Standard dentistry: paid by scheme. Includes plastic dentures every 4 years
  • Specialised dentistry: 80% scheme tariff, includes metal frame dentures, crowns and bridges and periodontics. Paid by scheme.
  • Implants: no benefit
  • In-hospital: 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:
  • 80% scheme tariff
  • , where function is impaired. 9-18yrs.
  • 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

.
.
MEDICATION:
Gold
Scheme Benefits Gap benefits
Chronic:
  • PMBs chronic: paid by scheme. 15% co-payment for non-DSP use
Acute (presrcibed) medication:
  • Paid from day-to-day benefit
Over-the-counter:
  • Limited to R1,810 per family
  • Paid from day-to-day benefit
Birth Control:
  • Meds: Paid from day-to-day benefit
  • Devices: paid from medical appliances benefit (R8,100 per family)
On Discharge:
  • R475
Biological:

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

.
.
OPTOMETRY:
Gold
Scheme Benefits Gap benefits
Optometry:
  • Limited to R2,790 per person every 2 years
  • Sub limits: Frames (R880), Lenses (one pair), Contact lenses (R1,330)
  • Paid from day-to-day benefit
  • Refractive surgery: subject to optical benefit
  • In addition, one pair of reading glasses (R160 limit) from the over-the-counter medicine 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

.
.
MENTAL HEALTH:
Gold
Scheme Benefits Gap benefits
In-hospital:
  • Psychiatric: R36,100 per family in and out of hospital, with sub limit of R14,700 for out-of hospital
  • No benefit
Out-of-hospital:
  • Psychiatric: R36,100 per family in and out of hospital, with sub limit of R14,700 for out-of hospital
  • No benefit
Trauma:
  • No benefit

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

.
.
OTHER BENEFITS:
Gold
Scheme Benefits Gap benefits
General Appliances:
  • R8,100 per family, in and out of hospital. Includes wheelchairs, orthopaedic appliances, incontinence equipment and contraceptive devices.
  • No benefit
1.1. Hearing Aids:
  • R14,300 per family every 5 years. Maximum R7,100 per ear.
  • Maintenance: R890, including batteries
  • 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

.
.
WELLNESS/PREVENTATIVE BENEFITS:
Gold
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

.
.
PROSTHETICS:
Gold
Scheme Benefits Gap benefits
Overal Limit:
  • R41,800 per family, subject to authorisation and protocols
  • 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