• Benefits, in-hospital, Momentum Plan, out-hospital, Scheme Plans

Momentum Custom Network (for hospitals) State (for chronic):
in-and-out of hospital benefits (2025)

Contents:

This page has overview information on: Costs, In-hospital, Out of Hospital and Medicine benefits for Momentum Custom Network (and State provider for chronic). Please consult and verify with the scheme or your broker for full benefits, and an explanation of all the "fine print".

Terminology:

  • PMBs: Prescribed Minimum Benefits. You can read more about PMBs, see a list of all PMB conditions or read more what "PMB only" benefit means.
  • DSPs: Designated Service Providers. Where stipulated, you must use specific providers to get full benefit.
  • Co-payment: Paid out of pocket, or out of savings account. Sometimes this is refundable to you if you have a gap product.
  • All schemes have extensive exclusions. We've tried to list the non-common ones here, but please consult your scheme or broker to get the full list.

Monthly Costs (2026)

(Other benefits: Costs | Inhospital | Out of hospital | Medication | Maternity | Cancer | Mental Health | Dentistry | Optometry | Other/Extra Benefits | Wellness | Prosthetics)

Momentum:Custom Associate (and State provider for chronic) (2026)
Main member: Adult member: Child member:
Total Cost pm:
  • R2,585
  • R1,956
  • R916
Savings:
  • No savings account option on this plan
  • The scheme might still cover some or all day-to-day claims. See below, and see benefits.
Children Rates:
  • Under 21yrs
  • Only pay for 3 children
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In-hospital Procedures (2025):

(Other benefits: Costs | Inhospital | Out of hospital | Medication | Maternity | Cancer | Mental Health | Dentistry | Optometry | Other/Extra Benefits | Wellness | Prosthetics)

Momentum: Custom Associate (and State provider for chronic)
Assume scheme pays all these costs, at 100% scheme rate, unless otherwise stated
GPs and Specialists:
  • GPs: 100% scheme rate
  • network Specialists: paid in full
  • non-network Specialists: 100% scheme rate
Gap Cover:
Can push payout up to 700% scheme rate
(Plans coming soon)
Hospital Choice:
Penalty for using other hospital:
  • 30% of hospital account
 Gap Cover:
Can cover the penalty in full
(Plans coming soon)
Co-payments:
  • R1,920 per authorisation, except for vehicle accidents, maternity, emergency treatment
  • Specialised radiology: R3,200 co-payment
  • Dental admissions: R3,450 and R6,500 co-payment
Also, additional R1,920 co-payment if in day hospital or an additional R3,840 co-payment if done in an overnight (acute) hospital for the following :
  • Arthroscopies
  • Back and neck surgery
  • Carpal Tunnel release
  • Functional nasal and sinus procedures
  • Joint replacements
  • Laparoscopies
  • Gastroscopies*,
  • Nail surgery*,
  • Cystoscopies, colonoscopies, sigmoidoscopies*,
  • Removing of extensive skin lesions*
  • * You still pay the first R1,920 co-payment if done in doctor's rooms
If the following are of low severity: no benefit
If high severity: R3,660 additional co-payment for in-hospital treatment:
  • Conservative back and neck treatment
  • Treatment of diseases of conjunctival
  • Treatment of headaches
  • Removing of minor skin lesions
  • Treatment of adult influenza
  • Treatment of adult respiratory tract infections
Note:
  • If you use a DSP (designated service provider), you never have to pay a co-payment for protocol treatment of a PMB (Prescribed Minimum Benefit). More info here
  • There might be other co-payments, especially if you don't use a DSP for a PMB or when buying medicine.
 Gap Cover:
Can cover most co-payments
(Plans coming soon)
Specialised Radiology:
  • MRI and CT scans, (MRCP), whole body radioisotope and PET scans: R3,200 co-payment, in and out of hospital
 Gap Cover:
Can cover most co-payments and increase sublimits
(Plans coming soon)
Scopes: Gap Cover:
Can cover most co-payments and increase sublimits
(Plans coming soon)
Supplementary Services: (Physio, etc)
  • 100% scheme rate
Transplants:
  • Recipient: Unlimited
  • Donor: R24,000 cadaver costs and R50,400 for live donor costs. Only covered if recipient is a member of the scheme
Dialysis:
  • Covered
Exclusions: If low severity, these are excluded:
  • Conservative back and neck treatment
  • Treatment of diseases of conjunctival
  • Treatment of headaches
  • Removing of minor skin lesions
  • Treatment of adult influenza
  • Treatment of adult respiratory tract infections
  • NB: See scheme's rules for all exclusions. All schemes have plenty!
 Gap Cover:
Coming soon
Alternatives to hospitals:
  • Medical rehabilitation, private nursing, hospice and step-down facilities: R64,000 per family
Casualty/ER:
  • PMBs only
Gap Cover:
Can cover ER claims
(Plans coming soon)
Other:
  • HIV related admissions: R85,600 per family, unless PMB
PMBs = Prescribed Minimum Benefits (more info) | DSP = Designated Service Provider

Out-of-hospital Procedures (2025):

(Other benefits: Costs | Inhospital | Out of hospital | Medication | Maternity | Cancer | Mental Health | Dentistry | Optometry | Other/Extra Benefits | Wellness | Prosthetics)

Momentum: Custom Associate (and State provider for chronic)
Assume scheme pays all these costs, at 100% scheme rate, unless otherwise stated
Main Member: Adult: Child:
Savings (per year):
  • No savings account option on this plan
  • The scheme might still cover some or all day-to-day claims. See below, and see benefits.
Other Day-to-Day Funds:
PMBs out of hospital:
  • All schemes must pay for the diagnosis, treatment and management of all PMB conditions, in or out of hospital. You can see a full list of the conditions here.
  • This can include consults with specialists, blood or other tests, radiology and medicine.
  • PMB benefits must never be paid from your savings account.
  • Schemes usually impose the use of specific providers for treatment of PMBs. Read more about that here.
  • See our Guide to PMBs for more information.
GP consultations:
  • 1 GP consult per person, paid by scheme, every 1-5 years (frequency depends on age)
  • Otherwise, no benefit unless PMB
Childcare:
  • Paediatrician: 2 consults, 0-12 months
  • Immunisations: Covered
 Gap Cover:
Can pay for child ER visits
(Plans coming soon)
Specialist consultations:
  • PMBs only
Pathology:
  • PMBs only
General radiology:
  • PMBs only
Specialised radiology:
  • MRI and CT scans, (MRCP), whole body radioisotope and PET scans: R3,200 co-payment, in and out of hospital
 Gap Cover:
Can pay co-payments and increase sublimits
(Plans coming soon)
Scopes: Gap Cover:
Can pay co-payments and increase sublimits
(Plans coming soon)
Supplementary Services: (Physio, etc)
  • PMBs only
General Appliances:
  • In-hospital: R8,030 per family
  • Out-of-hospital: No benefit
1.1. Hearing Aids:
  • No benefit
1.2. Wheelchairs:
  • No benefit
PMBs = Prescribed Minimum Benefits (more info) | DSP = Designated Service Provider

All benefits, including gap benefits, are subject to treatments and procedures being authorised by medical scheme. The benefits listed here are an indication only. Please verify all benefits and their conditions with the scheme.

Medication Benefit (2025):

(Other benefits: Costs | Inhospital | Out of hospital | Medication | Maternity | Cancer | Mental Health | Dentistry | Optometry | Other/Extra Benefits | Wellness | Prosthetics)

Momentum: Custom Associate (and State provider for chronic)
Assume scheme pays all these costs, unless otherwise stated
Main Member: Adult: Child:
Savings (per year):
  • No savings account option on this plan
  • The scheme might still cover some or all day-to-day claims. See below, and see benefits.
Other Day-to-Day Funds:
Chronic:
  • State facilities for chronic treatment
Acute (prescribed) medication:
  • No benefit
Over-the-counter:
  • No benefit
Birth Control:
  • No benefit
On Discharge:
  • 7 days supply
Biological:
  • PMBs only
PMBs = Prescribed Minimum Benefits (more info) | DSP = Designated Service Provider

All benefits, including gap benefits, are subject to treatments and procedures being authorised by medical scheme. The benefits listed here are an indication only. Please verify all benefits and their conditions with the scheme.

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