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Custom: Associated hospital - Any chronic

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Type of Medical Aid Plan: 
Hospital
Medical Aid Year: 
2020
Day to day Benefits: 

No benefit. You may add a HealthSaver to provide cover for your day-to-day healthcare needs

In Hospital Benefits
Are you prepared to use designated hospitals?: 
Yes
Hospital Rate of Payment: 
Unlimited at 100% Momentum Health Rate(MHR)
Hospitals: 

Associated hospital only for planned procedure admissions

Upfront Payments to hospitals: 

R1 570 standard upfront payment applies per admission, except for motor vehicle accidents, maternity confinements and emergency treatment. An additional upfront payment of R3 150 may apply to admissions where specialised procedures are required. If you use a hospital outside of the Associated Hospital Network, Momentum pays 70% of MHR and you are responsible for the other 30%

Casualty / Emergency Visits: 
Subject to HealthSaver, if available
Specialists: 
Full cover for Associated specialists. Other specialists at 100% of MHR
Other healthcare professionals eg. Physio, Occupational, Dietician: 
100% of MHR
Radiology and pathology: 
100% of MHR
Scopes (gastroscopy, colonoscopy, sigmoidoscopy and proctoscopy): 
Subject to pre-authorisation. Specialised procedure co-payment of R4 720 applies if performed in-hospital. Standard co-payment of R1 570 if performed out-of-hospital. Anaesthetists are covered up to R480
MRI and CT scans: 
Unlimited at 100% of MHR. Subject to pre-authorisation and co-payment of R2 620 per scan
ICU and High Care: 
Unlimited at 100% of MHR
Dialysis: 
Unlimited at 100% of MHR
Organ Transplants: 
Recipient: Unlimited at 100% of MHR. Donor is covered only if a member of Momentum Health: R19 500 for cadaver or R39 600 for live donor
Oncology / Cancer: 
R300 000 per beneficiary per annum, thereafter a 20% co-payment applies
Neck and Back Operations: 
100% of MHR. Specialised procedure co-payment of R4 720 applies. Subject to prosthesis limit
Joint Replacements: 
100% of MHR. Specialised procedure co-payment of R4 720 applies. Subject to prosthesis limit
Prosthesis: 

Internal: (including knee and hip replacements, permanent pacemakers, cochlear implants, etc.) R46 600 per beneficiary, per event, limited to 2 events per annum; Intraocular lenses: R5 500 per beneficiary, per event, limited to 2 events per annum. External: R21 900 per family

Medical and Surgical Appliances: 
In-hospital: R6 310 per family
Maternity Confinements: 
Unlimited at 100% of MHR
In Hospital Dentistry: 
Maxillofacial surgery only; impacted wisdom teeth & general anaesthesia for children < 7. Covers hospital and anaesthetist accounts only, with standard co-payment of R1 570. Dental specialist and maxillofacial surgeon paid from HealthSaver, if available
Take home Medicine: 
7 days supply
Rehabilitation, Hospice and Step-down facilities: 
R51 100 per family
Treatment for Mental Health: 
Subject to treatment at a preferred provider: R35 600 per beneficiary. Includes psychiatry and psychology. Drug and alcohol rehabilitation sub-limited to 21 days
HIV / AIDS: 
Any provider. Anti-retroviral treatment unlimited. HIV related admissions limited to R67 200 per family
Ambulance Service: 
Netcare 911 in an emergency
International Travel Benefit: 
R7.66m emergency cover, per beneficiary per 90-day journey. Includes R15 500 each for emergency optometry and dentistry and R765 000 terrorism cover. A co-payment of R1 710 applies per out-patient claim
Day-to-day benefits
GP consultations: 

Subject to HealthSaver, if available

Specialist consultations: 

Subject to HealthSaver, if available

Acute medicine: 

Subject to Healthsaver, if available

Over-the-counter (OTC) Medicine: 

Subject to Healthsaver, if available

Optometry benefits: 
Subject to Healthsaver, if available
Basic dentistry: 
Subject to Healthsaver, if available
Specialised Dentistry: 
Subject to Healthsaver, if available
Orthodontics: 

Subject to Healthsaver, if available

MRI and CT Scans (Out of Hospital): 
100% of MHR. Subject to pre-authorisation and co-payment of R2 620 per scan
Radiology and Pathology: 
Subject to Healthsaver, if available
Pregnancy benefits: 
Subject to registration on the Maternity Management programme between 8-20 weeks: 12 antenatal consults with midwife, GP or gynaecologist, 2x 2D scans and 2 home nurse visits after return from hospital. 2 paediatrician visits in baby's 1st year
Physiotherapy and Occupational Therapy day to day: 
Subject to Healthsaver, if available
Chronic Conditions
Provider: 
Any GP and Clicks, Dischem or Medipost pharmacies
Chronic Conditions: 

Diagnosis, treatment and care costs of 26 chronic conditions that fall under the PMB Chronic Disease List, issued by the Council for Medical Schemes. Subject to registration on the Chronic Management Programme, Scheme approval and the Custom specific formulary

Additional Chronic Conditions: 
None
Preventative Care Benefits
Preventative Benefits: 

From Health Platform Benefit, payable up to a maximum Rand amount per benefit. Health assessment screening(without pre-notification). The following benefits require pre-notification: dental consult, and age and frequency specific tests for pap smear, mammogram, DEXA bone density scan, general physical exam, prostate specific antigen, glaucoma, HIV test, flu and pneumococcal vaccines, tetanus diphtheria injection and paediatric immunisations as required by the Department of Health

Total Contributions
Total Contribution Main Member: 
2319.00
Total Contribution Adult: 
1830.00
Total Contribution Child*: 
818.00
Associated hospital - Any chronic
Risk Contributions
Risk Contribution Main Member: 
2319.00
Risk Contribution Adult: 
1830.00
Risk Contribution Child: 
818.00
Medical Aid Plan Name Term: 
Custom Associated Any