Keyhealth Essence:
in-and-out of hospital benefits (2025)

This page has overview information on: Costs, In-hospital, Out of Hospital and Medicine benefits for Keyhealth Essence. Please consult and verify with the scheme or your broker for full benefits, and an explanation of all the "fine print".

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Terminology:

• PMBs: Prescribed Minimum Benefits. You can read more about PMBs, see a list of all PMB conditions or read more what "PMB only" benefit means.
• DSPs: Designated Service Provders. Where stipulated, you must use specific specific providers to get full benefit.
• Co-payment: Paid out of pocket, or out of savings account. Sometimes this is refundable to you if you have a gap product
• All schemes have extensive exclusions. We've tried to list the non-common ones here, but please consult your scheme or broker to get the full list.

In-hospital Procedures (2025):

(Other benefits: Costs | Inhospital | Out of hospital | Medication | Maternity | Cancer | Mental Health | Dentistry | Optometry | Other/Extra Benefits | Wellness | Prosthetics)

Keyhealth: Essence
Assume scheme pays all these costs, at 100% scheme rate, unless otherwise stated
GPs and Specialists:	100% scheme rate	Gap Cover: Can push payout up to 700% scheme rate (Plans coming soon)
Hospital Choice:	Choose any Netcare or Lifecare, and Mediclinic in Western Cape, Bloemfontein and Polokwane
Penalty for using other hospital:	Use of non-Network hospital: 30% penalty	Gap Cover: Can cover the penalty in full (Plans coming soon)
Co-payments:	Note: A co-payment is a fee your medical aid can insist you pay, regardless of how much the doctor/charges. It's not the same as an "excess" payment (which is when a doctor charges more than the medical aid rate). If you use a DSP (designated service provider), you never have to pay a co-payment for protocol treatment of a PMB (Prescribed Minimum Benefit). More info here There might be other co-payments if you don't use a DSP, especially if you are being treated for a PMB or when buying medicine.	Gap Cover: Can cover most co-payments (Plans coming soon)
Specialised Radiology:	MRI and CT Scans: R20,900 per family. In and out of hospital. PET Scans: PMBs only	Gap Cover: Can cover most co-payments and increase sublimits (Plans coming soon)
Scopes:	Colonoscopy and gastroscopy: No co-payment if done in DSP hospital, or with DSP specialist out of hospital, or for PMB conditions	Gap Cover: Can cover most co-payments and increase sublimits (Plans coming soon)
Supplementary Services: (Physio, etc)	100% scheme rate
Transplants:	PMBs only
Dialysis:	PMBs only
Exclusions:	Varicose vein surgery Facet joint injections Rhizotomy Reflux Surgery Back and Neck surgery, incl spinal fusion Joint replacement NB: See scheme's rules for all exclusions. All schemes have plenty!	Gap Cover: Coming soon
Alternatives to hospitals:	Hospice, private nursing, rehab, step-down facilities and wound care : PMBs only
Casualty/ER:	PMBs only	Gap Cover: Can cover ER claims (Plans coming soon)
Other:
PMBs= Prescribed Minimum Benefits (more info) | DSP= Designated Service Provider

Out-of-hospital Procedures (2025):

(Other benefits: Costs | Inhospital | Out of hospital | Medication | Maternity | Cancer | Mental Health | Dentistry | Optometry | Other/Extra Benefits | Wellness | Prosthetics)

Keyhealth: Essence
Assume scheme pays all these costs, at 100% scheme rate, unless otherwise stated
Main Member: Adult: Child: Savings (per year): No savings account option on this plan The scheme might still cover some or all day-to-day claims. See below, and see benefits. Other Day-to-Day Funds:
PMBs out of hospital:	All schemes must pay for the diagnosis, treatment and management of all PMB conditions, in or out of hospital. You can see a full list of the conditions here. This can include consults with specialists, blood or other tests, radiology and medicine PMB benefits must never be paid from your savings account Schemes usually impose the use of specific providers for treatment of PMBs. Read more about that here. See our Guide to PMBs for more information.
GP consultations:	PMBs only
Childcare:	Paediatrician: 2 consults 0-1yr, and 1 consult 1-2yrs Immunisations: Up to 6yrs Hearing screening test: Newborns, aged 0-8 weeks Eye test: One per child, 0-7yrs, once	Gap Cover: Can pay for child ER visits (Plans coming soon)
Specialists consultations:	PMBs only
Pathology:	PMBs only
General radiology:	PMBs only
Specialised radiology:	MRI and CT Scans: R20,900 per family. In and out of hospital. PET scans: No benefit	Gap Cover: Can pay co-payments and increase sublimits (Plans coming soon)
Scopes:	Colonoscopy and gastroscopy: No co-payment if done in DSP hospital, or with DSP specialist out of hospital, or for PMB conditions	Gap Cover: Can pay co-payments and increase sublimits (Plans coming soon)
Supplementary Services: (Physio, etc)	PMBs only
General Appliances:	Wheelchairs, orthopaedic appliances, incontinence equipment, contraceptive devices: R9,200 per family, in and out of hospital.
1.1. Hearing Aids:	No benefit
1.2. Wheelchairs:	See "General Appliances" limit
PMBs= Prescribed Minimum Benefits (more info) | DSP= Designated Service Provider

Medication Benefit (2025):

(Other benefits: Costs | Inhospital | Out of hospital | Medication | Maternity | Cancer | Mental Health | Dentistry | Optometry | Other/Extra Benefits | Wellness | Prosthetics)

Keyhealth: Essence
Assume scheme pays all these costs, unless otherwise stated
Main Member: Adult: Child: Savings (per year): No savings account option on this plan The scheme might still cover some or all day-to-day claims. See below, and see benefits. Other Day-to-Day Funds:
Chronic:	27 PMB conditions: Covered. You can see the full PMB list here. .
Acute (prescribed) medication:	PMBs only
Over-the-counter:	No benefit
Birth Control:	Contraceptive device: From "Appliances" benefit, R9,200 per family Tablets: R185 every 20 days Injectables : R285 every 72 days
On Discharge:	R670 per admission
Biological:	PMBs only
View other benefits for this plan: In-hospital | Out-of-hospital | Medication | Maternity | Cancer | Mental Health | Dentistry | Optometry | Other/Extra Benefits | Wellness | Prosthetics You can also: Compare any two plans, side by side | View all the Keyhealth plans, with costs and brief summary. Find all other open medical aid plans here.
PMBs= Prescribed Minimum Benefits (more info) | DSP= Designated Service Provider