Exclusions: Note that all schemes have extensive exclusions. We've tried to list the major ones, but you must consult with your scheme to get the full list.
All treatments and procedures are subject to authorisation and protocols
All benefits are listed as an indication only. Please verify with your broker and scheme
Assume scheme pays all these costs, unless otherwise stated
non-Network Specialists:
200% scheme rate
Scheme rate is set by Momentum
network Specialists:
Covered in full
non-Network GPs:
200% scheme rate
network GPs:
Covered in full
Hospital Choice:
Any hospital
Day Hospitals:
See co-payments, below to see which procedures are covered in a Day Hospital
Penalty for using other hospital:
n/a
You don't pay a penalty if admission was unavoidable due an emergency
Other Co-payments:
Specialised radiology: R2,770 co-payment
Dental admissions: R3,300 and R6,150 co-payment
Also, additional R1,830 co-payment if in day hospital or an additional R3,660 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*
* No co-payment if done in doctor's rooms
If the following are of low severity: no benefit
If high severity: R3,660 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
* There might be other co-payments if you don't use scheme-chosen provider for some services.
* Treatment required for PMB level care is always paid by scheme, with no co-payment, if you follow the protocols. That means that these co-payments might not apply in your case! More info here
Specialised Radiology:
MRI and CT scans, (MRCP), whole body radioisotope and PET scans: R2,770 co-payment, in and out of hospital
No limits or co-payments for PMB level care and/or for emergency
Supplementary Services: (Physio, etc)
100% scheme rate
No limits or co-payments for PMB level care and/or for emergency
Transplants:
Recipient: Unlimited
Donor: R26,100 cadaver costs and R53,000 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
* Treatment required for PMB level of care is always paid by scheme, if you follow the protocols. It cannot be excluded. More info here.
* All schemes have extensive exclusions. We've tried to list the major ones here, but please consult your scheme or broker to get the full list
Alternatives to hospitals:
Medical rehabilitation, private nursing, hospice and step-down facilities: R64,000 per family
All medical aids 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
The benefit is paid by the scheme, and not out of your savings account
If you have no day-to-day funds, you still have cover for PMBs
Schemes usually impose the use of specific providers for treatment of PMBs. Read more about that here.
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.
You might be required to use specific pharmacies and be limited to specific medicines
Acute (presrcibed) medication:
From day-to-day benefit
Over-the-counter:
From day-to-day benefit
Birth Control:
From day-to-day benefit
On Discharge:
7 days supply
Biological:
PMBs only
Treatment that is required (by law) for PMB conditions is always paid paid by scheme, with no co-payment, if you follow the protocols. More info here.)
Note:
Schemes have very strict rules about where you can get your medicine to get full benefit. We do not list the requirements here, so confirm with your scheme before you collect your medicine.
Formulary: A pre-defined list of approved medicines. Each plan has a different list, and might not pay for non-listed medicine. Confirm with your scheme whether your required medicine is covered by them.
PMBs: Prescribed Minimum Benfits. To read more about PMBs click here
DSPs: Designated Service Provders. Where stipulated, you must use specific 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 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.
A quick guide to how you can change your medical aid plan, including the resignation procedure, and things to look out for, such as imposed waiting periods from your new scheme
