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

Overall annual day-to-day limit of R25 900 per beneficiary. Paid at 100% of MHR. Subject to annual sub-limits

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

Any

Casualty / Emergency Visits: 
Subject to overall annual day-to-day limit of R25 900 per beneficiary
Specialists: 
Full cover for Associated specialists. Other specialists at 300% of MHR
Other healthcare professionals eg. Physio, Occupational, Dietician: 
Unlimited at 100% of MHR
Radiology and pathology: 
Unlimited at 100% of MHR
Scopes (gastroscopy, colonoscopy, sigmoidoscopy and proctoscopy): 
Subject to pre-authorisation. Anaesthetists are covered up to R1 200
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: 
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: R21 500 for cadaver or R43 600 for live donor
Oncology / Cancer: 
Unlimited at 100% of MHR
Neck and Back Operations: 
Unlimited at 100% of MHR. Subject to prosthesis limit
Joint Replacements: 
Unlimited at 100% of MHR. 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: R30 100 per family. Sub-limit of R17 500 for hearing aids; subject to overall annual day-to-day limit of R25 900 per beneficiary
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. Dental specialist and maxillofacial surgeon paid from Day-to-Day Benefit and accumulate towards limit of R25 900 pb
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: 
Any provider. Anti-retroviral treatment unlimited. HIV related admissions limited to R72 700 per family
Ambulance Service: 
Netcare 911 in an emergency
International Travel Benefit: 
R9.01m 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 overall annual day-to-day limit of R25 900 per beneficiary

Specialist consultations: 

Subject to overall annual day-to-day limit of R25 900 pb

Acute medicine: 

R20 300 per beneficiary, R33 200 per family. Subject to overall annual day-to-day limit of R25 900 pb

Over-the-counter (OTC) Medicine: 

No benefit

Optometry benefits: 
Overall limit of R4 530 per beneficiary. Frame sub-limit of 2 320. Subject to overall annual day-to-day limit of R23 500 pb
Basic dentistry: 
Subject to overall annual day-to-day limit of R25 900 pb
Specialised Dentistry: 
R15 600 per beneficiary, R37 400 per family. Both in- and out-of-hospital dental specialist accounts accumulate towards the limit. Subject to overall annual day-to-day limit of R25 900 pb
Orthodontics: 

R15 600 per beneficiary, R37 400 per family. Subject to overall annual day-to-day limit of R25 900 pb

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: 
Subject to overall annual day-to-day limit of R25 900 pb
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: 
Subject to overall annual day-to-day limit of R25 900 pb
Chronic Conditions
Provider: 
Any provider
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 a comprehensive formulary

Additional Chronic Conditions: 
36 additional conditions - accumulate to overall annual day-to-day limit of R25 900 pb
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: 
10187.00
Total Contribution Adult: 
8147.00
Total Contribution Child*: 
2340.00
Summit
Medical Aid Plan Name Term: 
Summit