Hospital Rate of Payment:
Hospital accounts are covered in full at the rate agreed upon with the hospital group. No overall annual limit applies.
Upfront Payments to hospitals:
Certain specialist referral procedures: In hospital: R1300 Out of hospital: nil.
However; an additional R750 co-pay will apply if you did not obtain an appropriate GP referral.
R1 650 for Maxillo-facial surgery.
Casualty / Emergency Visits:
Subject to Day-to-day Benefit.
Specialists:
Associated specialists covered in full. Other specialists covered up to 200% of Momentum Health Rate.
Other healthcare professionals eg. Physio, Occupational, Dietician:
Unlimited within the provisions of the General Rule mentioned above.
Radiology and pathology:
No annual limit applies, subject to R2 150 co-payment per scan and pre-authorisation.
Scopes (gastroscopy, colonoscopy, sigmoidoscopy and proctoscopy):
In-hospital: Paid by Scheme R1300 co-payment per authorisation applies. Out-of-hospital: Paid by Scheme R0 co-payment. An additional R750 co-payment will apply if you do not obtain an appropriate GP referral.
MRI and CT scans:
No annual limit applies, subject to R2 150 co-payment per scan and pre-authorisation.
Dialysis:
Renal dialysis. No annual limit applies. Beneficiaries who have selected State as their chronic provider need to make use of State facilities for renal dialysis.
Organ Transplants:
Organ transplants (recipient), No annual limit applies. Organ transplants (donor), Only covered when recipient is a member of the Scheme. R18 600 cadaver costs. R37 700 live donor costs (incl. transportation).
Oncology / Cancer:
R500 000 per beneficiary per year, thereafter a 20% co-payment applies. The Momentum Health medicine rate applies to chemotherapy and adjuvent medication.
Neck and Back Operations:
Can only be performed in-hospital. Paid by Scheme, R1 300 co-payment per authorisation applies. An additional R750 co-payment will apply if you do not obtain an appropriate GP referral.
Joint Replacements:
Can only be performed in-hospital. Paid by Scheme, R1 300 co-payment per authorisation applies. An additional R750 co-payment will apply if you do not obtain an appropriate GP referral.
Medical and Surgical Appliances:
Medical and surgical appliances in-hospital (such as support stockings, knee and back braces etc.) R6 300 per family.
In Hospital Dentistry:
Ltd to maxillo-facial surgery(excl implants), impacted wisdom teeth & general anaesthesia for children <7. Hospital accounts paid from Major Medical Benefit R1650 co-payment. Dental, dental specialist & maxillo-facial surgeon accounts paid from Savings.
Rehabilitation, Hospice and Step-down facilities:
Treatment for Mental Health:
Mental health incl. psychiatry and psychology - drug and alcohol rehabilitation. R34 400 per beneficiary, 21-day sub-limit applies to drug and alcohol rehabilitation, subject to treatment at preferred provider.
HIV / AIDS:
Immune deficiency related to HIV. Anti-retroviral treatment. HIV related admissions. At your chosen network provider. No annual limit applies. R65 900 per family.
Ambulance Service:
Emergency evacuation in South Africa by Netcare 911.
International Travel Benefit:
International emergency cover & evacuation by ISOS. R8.22 million. Includes R1500 for emergency optometry, R15500 for emergency dentistry and R765000 terrorism cover. A R1550 co-payment applies per out-patient claim. Per beneficiary per 90-day journey.
