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Extender: Any Hospital - State Chronic

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

There is a General Rule applicable to Day-to-Day Benefits: 25% of the total contribution is available as Savings. If this component is not enough to cover your annual day-to-day expenses, you will have a self-funding gap, when you pay your claims, out of your pocket, up to the Threshold of: Member = R22 900; Adult dependant = R20 000; Per child (maximum of 3) = R6 600. When you reach this Threshold, claims are paid by the Scheme from Extended Cover, subject to sub-limits and MHR. Sub-limits apply before and after the Threshold is reached

In Hospital Benefits
Are you prepared to use designated hospitals?: 
No
Hospital Rate of Payment: 
Unlimited at 100% Momentum Health Rate(MHR).
Hospitals: 

Any

Upfront Payments to hospitals: 

An upfront payment of R3 150 may apply to admissions where specialised procedures are required

Casualty / Emergency Visits: 
Subject to Day-to-Day Benefit
Specialists: 
Full cover for Associated specialists. Other specialists at 200% 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 R3 150 applies if performed in-hospital. No co-payment if performed out-of-hospital. Anaesthetists are covered up to R1 000
MRI and CT scans: 
Unlimited at 100% of MHR. Subject to pre-authorisation and co-payment of R2 370 per scan
ICU and High Care: 
No annual limit applies.
Dialysis: 
Unlimited at 100% of MHR, As you chose State as your chronic provider, you need to use State facilities
Organ Transplants: 
Recipient: Unlimited at 100% of MHR. Donor is covered only if a member of Momentum Health: R21 500 for cadaver or R43 600 for live donor
Oncology / Cancer: 
R500 000 per beneficiary per annum, thereafter a 20% co-payment applies. As you chose State as your chronic provider, you need to obtain your oncology treatment from a Scheme authorised oncologist and oncology medication from Medipost
Neck and Back Operations: 
100% of MHR. Specialised procedure co-payment of R3 150 applies. Subject to prosthesis limit
Joint Replacements: 
100% of MHR. Specialised procedure co-payment of R3 150 applies. Subject to prosthesis limit
Prosthesis: 

Internal: (including knee and hip replacements, permanent pacemakers etc.) R69 200 per beneficiary, per event, limited to 2 events per annum; Intraocular lenses: R7 170 per beneficiary, per event, limited to 2 events per annum; Cochlear implants: R183 000 per beneficiary, limited to 1 event per annum. External: R24 000 per family

Medical and Surgical Appliances: 
In-hospital: R6 950 per family. Out-of-hospital: R24 500 per family. Sub-limit of R7 390 per family for hearing aids; subject to pre-authorisation
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 a co-payment of R1 500. Dental specialist and maxillofacial surgeon paid from Day-to-Day Benefit
Take home Medicine: 
7 days supply
Rehabilitation, Hospice and Step-down facilities: 
R55 000 per family
Treatment for Mental Health: 
Subject to treatment at a preferred provider: R37 900 per beneficiary. Includes psychiatry and psychology. Drug and alcohol rehabilitation sub-limited to 21 days
HIV / AIDS: 
At a State provider. Anti-retroviral treatment unlimited. HIV related admissions limited to R72 700 per family
Ambulance Service: 
Netcare 911 in an emergency
International Travel Benefit: 
R8.22m 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: 

Any GP, paid at 100% of MHR

Specialist consultations: 

100% of MHR

Acute medicine: 

R17 500 per beneficiary, R33 100 per family

Over-the-counter (OTC) Medicine: 

Subject to Savings (does not accumulate to Threshold)

Optometry benefits: 
Overall limit of R4 140 per beneficiary. Frame sub-limit of R2 260
Basic dentistry: 
Unlimited within the provisions of the General Rule
Specialised Dentistry: 
R13 400 per beneficiary, R35 200 per family. Both in- and out-of-hospital dental specialist accounts accumulate towards the limit
Orthodontics: 

R13 400 per beneficiary, R35 200 per family. Both in- and out-of-hospital dental specialist accounts accumulate towards the limit

MRI and CT Scans (Out of Hospital): 
100% of MHR. Subject to pre-authorisation and co-payment of R2 370 per scan
Radiology and Pathology: 
Unlimited within the provisions of the General Rule
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, pathology and 3 home nurse visits after return from hospital. 2 paediatrician visits in baby's 1st year
Physiotherapy and Occupational Therapy day to day: 
Unlimited within the provisions of the General Rule
Chronic Conditions
Provider: 
State facility
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 State formulary and medical management

Additional Chronic Conditions: 
36 additional conditions. Limited to R10 300 per family per annum
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: 
5713.00
Total Contribution Adult: 
4691.00
Total Contribution Child*: 
1679.00
Any Hospital - State Chronic
Annual Medical Savings Account
Annual Medical Savings Main Member: 
17136.00
Annual Medical Savings Adult: 
14076.00
Annual Medical Savings Child*: 
5040.00
Monthly Medical Savings
Savings Child*: 
420.00
Savings Adult: 
1173.00
Savings Main Member: 
1428.00
Annual Threshold Amounts
Annual Threshold Main Member: 
22900.00
Annual Threshold Adult: 
20000.00
Annual Threshold Child*: 
6600.00
Risk Contributions
Risk Contribution Main Member: 
4285.00
Risk Contribution Adult: 
3518.00
Risk Contribution Child: 
1259.00
Medical Aid Plan Name Term: 
Extender Any State