Are you prepared to use designated hospitals?:
Hospital Rate of Payment:
Hospital accounts are covered in full at the rate agreed upon (100% of tariff) with the hospital group. No overall annual limit applies.
Casualty / Emergency Visits:
Casualty or after-hours visits subject to HealthSaver, if available.
Specialists:
Associated specialists covered in full. Other specialists covered up to 100% of Momentum Health Rate.
Other healthcare professionals eg. Physio, Occupational, Dietician:
Scopes (gastroscopy, colonoscopy, sigmoidoscopy and proctoscopy):
In-hospital: Paid by Scheme. Co-payment of R4500 per authorisation applies. Out-of-hospital; co-payment of R1500 applies. An additional co-payment of R750 will apply if you do not obtain an appropriate GP referral.
MRI and CT scans:
No annual limit applies, subject to R2 500 co-payment per scan and pre-authorisation. In or out of hospital.
Dialysis:
Renal dialysis. No annual limit applies. Beneficiaries who have selected State as their chronic provider need to make use of State facilities.
Organ Transplants:
Organ transplants (recipient), Unlimited. 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:
R300 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:
Paid by scheme. Co-payment of R4 500 per authorisation applies. An additional R750 co-payment will apply if you do not obtain an appropriate GP referral.
Joint Replacements:
Paid by Scheme. R1 300 co-payment applies. An additional R750 co-payment will apply if you do not obtain an appropriate GP referral.
Medical and Surgical Appliances:
In-hospital (such as support stockings, knee and back braces etc.) R6 130 per family.
In Hospital Dentistry:
Maxillofacial surgery only (no implants); impacted wisdom teeth & general anaesthesia for children <7. Hospital accounts are paid from Risk: co-payment of R1500. Dental, dental specialist & maxillofacial surgeon accounts paid from HealthSaver.
Rehabilitation, Hospice and Step-down facilities:
Treatment for Mental Health:
Mental health incl. psychiatry and psychology - drug and alcohol rehabilitation. R33 900 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. At your chosen network provider. Anti-retroviral treatment. No annual limit applies. HIV related admissions. R65 900 per family.
Ambulance Service:
Emergency evacuation in South Africa by Netcare 911.
International Travel Benefit:
International emergency cover & evacuation by ISOS. R7.66 million. Includes R15 500 for emergency optometry, R15 500 for emergency dentistry and R765000 terrorism cover. A R1630 co-payment applies per out-patient claim. Per beneficiary per 90-day journey.
