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Momentum Health 2018 Incentive Option - Associated Hospital & State Chronic

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Type of Medical Aid Plan: 
New Generation
Medical Aid Year: 
2018
Day to day Benefits: 

Subject to HealthSaver, if available

Co-payments: 
Co-payments may apply for specialist referral procedures.
In Hospital Benefits
Are you prepared to use designated hospitals?: 
Yes
Hospital Rate of Payment: 
Hospital accounts are covered in full at the rate agreed upon with the hospital group. No overall annual limit applies.
Hospitals: 

Momentum Associated network hospitals

Upfront Payments to hospitals: 

R1 300 per authorisation for certain procedures. If performed out of hospital no co-payment. An additional R750 co-pay will apply if you do not obtain an appropriate GP referral.

Casualty / Emergency Visits: 
Subject to Savings.
Specialists: 
Associated specialists covered in full. Other specialists covered up to 200% of Momentum Health Rate.
Other healthcare professionals eg. Physio, Occupational, Dietician: 
Unlimited
Radiology and pathology: 
Unlimited
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.
ICU and High Care: 
No annual limit applies.
Dialysis: 
No annual limit applies.
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: 
R400 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: 
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: 
R1 300 co-payment per authorisation applies. An additional R750 co-payment will apply if you do not obtain an appropriate GP referral.
Prosthesis: 

Internal: (including knee & hip replacements, permanent pacemakers). Cochlear implants: R152 400 per beneficiary maximum of 1 event per year. Intraocular lenses:R6 500 per beneficiary, per event, maximum of 2 events per year. Other internal prostheses: R46 400 per beneficiary, per event , maximum of 2 events per year. External (such as artificial arms or legs, etc) R21 500 per family.

Medical and Surgical Appliances: 
In-hospital (support stockings, knee and back braces etc.) R5 950 per family.
Maternity Confinements: 
No annual limit applies
In Hospital Dentistry: 
Maxillofacial surgery only (no implants), impacted wisdom teeth & general anaesthesia for children <7. Hospital accounts paid from Major Medical Benefit R1650 co-payment. Dental, dental specialist & maxillofacial surgeon accounts paid from Savings.
Take home Medicine: 
7 days’ supply.
Rehabilitation, Hospice and Step-down facilities: 
R46 6400 per family.
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 million. Includes R15 500 for emergency optometry, R15 500 for emergency dentistry and R765 000 terrorism cover. A R1 550 co-payment applies per out-patient claim, per beneficiary per 90-day journey.
Day-to-day benefits
GP consultations: 

Subject to available savings.

Specialist consultations: 

Subject to available savings

Acute medicine: 

Subject to available savings

Over-the-counter (OTC) Medicine: 

Subject to available savings

Optometry benefits: 
Optical and optometry (Incl. contact lenses and refractive eye surgery), Subject to Savings, if available.
Basic dentistry: 
Subject to available savings
Specialised Dentistry: 
Subject to available savings
Orthodontics: 

Subject to available savings

MRI and CT Scans (Out of Hospital): 
Covered from Major Medical Benefit, subject to R2 150 co-payment per scan and pre-authorisation.
Radiology and Pathology: 
Subject to available savings
Pregnancy benefits: 
12 Antenatal visits (Midwives, GP* or gynaecologist), Urine tests (dipstick) included, 2 pregnancy scans, 2 Paediatrician visits, 18-Month Subscription to online antenatal & postnatal classes & online video consultation with lactation specialist.
Physiotherapy and Occupational Therapy day to day: 
Subject to available savings
Chronic Conditions
Provider: 
State.
Chronic Conditions: 

26 conditions, according to Chronic Disease List(CDL) in Prescribed Minimum Benefits - no annual limit applies. CDL: Addison’s disease, Asthma, Bipolar mood disorder, Bronchiectasis, Cardiac dysrhythmias, Cardiac failure, Cardiomyopathy, Chronic obstructive pulmonary disease (COPD), Chronic renal disease, Coronary artery disease, Crohn’s disease (excl. biologicals such as Revellex*), Diabetes insipidus, Diabetes mellitus Type 1, Diabetes mellitus Type 2, Epilepsy, Glaucoma, Haemophilia, Hyperlipidaemia, Hypertension, Hypothyroidism, Multiple sclerosis (excl. biologicals such as Avonex*, subject to protocols), Parkinson’s disease, Rheumatoid arthritis (excl. biologicals such as Revellex and Enbrel*), Schizophrenia, Systemic lupus erythematosus, Ulcerative colitis

Additional Chronic Conditions: 
6 additional conditions - limited to R9 300 per family per year. Acne, ADHD (Attention Deficit Hyperactivity Disorder), Allergic rhinitis, Eczema, Pemphigus, Psoriasis
Preventative Care Benefits
Preventative Benefits: 

Health Platform: Health Assessment; Blood pressure test, Choleaterol, blood sugar, height, weight and waist circumference. Dental Consultation, Pap smear <15 years+, Mammogram >38 years+, Bone density scan >50 years +, Prostate Specific Antigen- men >40+ years, Flu and Pneumococcal vaccines as per protocols. Maternity program.

Total Contributions
Total Contribution Main Member: 
1834.00
Total Contribution Adult: 
1439.00
Total Contribution Child*: 
711.00
Incentive Option - Associated Hospital & State Chronic
Annual Medical Savings Account
Annual Medical Savings Main Member: 
2196.00
Annual Medical Savings Adult: 
1728.00
Annual Medical Savings Child*: 
852.00
Monthly Medical Savings
Savings Child*: 
71.00
Savings Adult: 
144.00
Savings Main Member: 
183.00
Risk Contributions
Risk Contribution Main Member: 
1651.00
Risk Contribution Adult: 
1295.00
Risk Contribution Child: 
640.00