Momentum Custom Network (State for chronic): 2020

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Custom Associate (and State provider for chronic)
2020 Costs:
Total Cost pm:

Main member:

R1,642

Adult:

R1,242

Child:

R582
Savings (per year):
  • No savings option on this plan



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IN HOSPITAL PROCEDURES:
Custom Associate (and State provider for chronic)
Scheme Benefits: Notes and Links:
non-Network Specialists:
  • The Blue Plan gap cover will increase this to 500% scheme rate
network Specialists:
  • Covered in full
  • The Blue Plan gap cover will increase this to 500% scheme rate
non-Network GPs:
  • 100% scheme rate
  • The Blue Plan gap cover will increase this to 500% scheme rate
network GPs:
  • Covered in full
  • The Blue Plan gap cover will increase this to 500% scheme rate
Hospital Choice:
  • Network hospital
Penalty for using other hospital:
  • 30% of hospital account
Specialised Radiology:
  • R2,620 co-payment
Supplementary Services: (Physio, etc)
  • The Blue Plan gap cover will increase this to 500% scheme rate
Transplants:
  • Recipient: Unlimited
  • Donor: R19,500 cadaver costs and R39,600 for live donor costs. Only covered if recipient is a member of the scheme
Co-payments:
  • R1,570 per authorisation, except for vehicle accidents, maternity and emergency treatment
In addition:
  • Arthroscopies
  • Back and neck surgery
  • Carpal Tunnel release
  • Functional nasal and sinus procedures
  • Joint replacements
  • Laparoscopies
  • R3,150 additional co-payment
  • Gastroscopies,
  • Nail surgery,
  • Cystoscopies, colonoscopies, sigmoidoscopies,
  • Removing of extensive skin lesions
  • R3,150 additional co-payment if done in hospital
  • Conservative back and neck treatment
  • Treatment of diseases of conjuctiva
  • Treatment of headaches
  • Removing of minor skin lesions
  • Treatment of adult influenza
  • Treatment of adult respiratory tract infections
  • If out of hospital, there is no benefit
  • In-hospital: R3,150 additional co-payment
  • Specialised radiology: R2,620 co-payment
Alternatives to hospitals:
    Medical rehabilitation, private nursing, hospice and step-down facilities: R51,100 per family. Paid by scheme.
Casualty:
  • No benefit, unless PMB
  • Both the Blue Plan and Red Plan gap cover will pay up to R20,000 per person for unpaid casualty costs in event of emergency
Other:
Note:
  • Gap cover is an add-on to your medical aid, not a stand alone product
  • Gap cover has a maximum benefit payout of R157,000 per person per year for all gap benefits (except dread disease and premium waiver benefits which do not count towards the R157,000 limit)
  • Gap only supplements payment for procedures approved or authorised by your medical aid, and does not cover “penalties” (such as if, for example, you choose a non-DSP doctor for your procedure when the plan required a DSP doctor)



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All benefits, including gap benefits, are subject to treatments and procedures being authorised by medical scheme.
The gap benefits listed are for AskAdam gaps, unless otherwise stated. Actual benefits depend on gap choice option.

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OUT OF HOSPITAL BENEFITS (non-PMB):
Custom Associate (and State provider for chronic)
Scheme Benefits Notes and Links:
Main Member: Adult: Child:
Savings /yr: No savings option on this plan
General info:
  • Consider getting Primary Health Care (PHC) (medical insurance) that will cover you for all GP visits, some specialist visits, acute meds, minor out of hospital procedures, some radiology and pathology, dentistry, optometry and more. It's an excellent complement to a hospital plan.
  • R370/main | R245/adult | R110/child
  • Read more here
GP consultations:
  • 1 GP consult per person, paid by scheme, every 1-5 years (frequency depends on age)
  • Otherwise, no benefit unless PMB
  • See Primary Health Care benefit above
Childcare:
  • 2 consults with paediatrician, 0-12 months
Specialists consultations:
  • No benefit, unless PMB
  • See Primary Health Care benefit above
Pathology:
  • No benefit, unless PMB
  • See Primary Health Care benefit above
General radiology:
  • No benefit, unless PMB
  • See Primary Health Care benefit above
Specialised radiology:
  • R2,620 co-payment
Supplementary Services: (Physio, etc)
  • No benefit, unless PMB



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MATERNITY BENEFITS:
Custom Associate (and State provider for chronic)
Scheme Benefits Notes and Links:
Hospital stay:
  • 100% scheme rate
  • The Blue Plan gap cover will increase this to 500% scheme rate
Consultations:
  • 12 consults, paid by scheme
  • 1 consult from nurse home visit, day after return from hospital
  • 1 consult from nurse home visit, 2 weeks after above visit
Scans:
  • 2 x 2D scans, paid by scheme



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CANCER (ONCOLOGY):
Custom Associate (and State provider for chronic)
Scheme Benefits Notes and Links:
Overall coverage (in and out of hospital):
  • R300,000 per person, with a 20% co-payment thereafter



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DENTISTRY:
Custom Associate (and State provider for chronic)
Scheme Benefits Notes and Links:
Standard Dentistry:
  • 1 consult per person paid by scheme
  • Consider getting Primary Health Care (medical insurance) that will cover you for a lot of out of hospital claims, including standard dentistry like scaling, polishing, fillings, extractions, root canals and more. It's an excellent complement to a hospital plan.
  • R370/main | R245/adult | R110/child
  • Read more here
Specialised Dentistry:
  • Specialised dentistry: no benefit
In-Hospital Dentistry:
  • In-hospital: maxillo-facial surgery, impacted wisdom teeth and general anaesthesia for children under 7yrs: Hospital and anaesthetist accounts paid by scheme, withR1,570 co-payment and surgeon accounts paid out-of-pocket
Orthodontics:
  • No benefit
Maxillo Facial Surgery:
  • See above



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MEDICATION:
Custom Associate (and State provider for chronic)
Scheme Benefits: Notes and Links:
Chronic:
  • All medical aid plans pay for treatment of the 27 CDL conditions as required by law. This includes medicine as well as GP or specialist consults, tests etc. Find out more
  • Must be obtained from State providers
Acute (presrcibed) medication:
  • No benefit
  • Consider getting Primary Health Care (medical insurance) that will cover you for all GP visits, some specialist visits, acute meds, minor out of hospital procedures, some radiology and pathology, dentistry, optometry and more. It's an excellent complement to a hospital plan.
  • R370/main | R245/adult | R110/child
  • Read more here
Over-the-counter:
  • No benefit
Birth Control:
  • No benefit
On Discharge:
  • 7 days supply
Biological:
  • No benefit, unless PMB level of care



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OPTOMETRY:
Custom Associate (and State provider for chronic)
Scheme Benefits: Notes and Links:
Optometry:
Limit:No benefit
Consult:n/a
Frames:n/a
Single lensesn/a
Bifocals:n/a
Multifocalsn/a
Contactsn/a
Refractive Surgery:n/a
Notes:n/a
  • Consider getting Primary Health Care (medical insurance) that will cover you for all GP visits, some specialist visits, acute meds, minor out of hospital procedures, some radiology and pathology, dentistry, optometry and more. It's an excellent complement to a hospital plan.
  • R370/main | R245/adult | R110/child
  • Read more here



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MENTAL HEALTH:
Custom Associate (and State provider for chronic)
Scheme Benefits Notes and Links:
In-hospital:
  • R35,600 per person, at preferred provider
Out-of-hospital:
  • PMBs only
Trauma:
  • PMB conditions are covered for in and out of hospital treatment. For a full list see here.
  • Example of PMB condition: Acute stress disorder accompanied by recent significant trauma, including physical or sexual abuse. Treatment includes hospital admission for psychotherapy / counselling up to 3 days, or up to 12 outpatient psychotherapy / counselling contacts



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OTHER BENEFITS:
Custom Associate (and State provider for chronic)
Scheme Benefits Notes and Links:
General Appliances:
  • In-hospital: R6,310 per family
  • Out-of-hospital: No benefit
1.1. Hearing Aids:
  • No benefit
1.2. Wheelchairs:
  • No benefit
Dialysis:
  • Unlimited
International Insurance:
  • R7.66 million international emergency cover. Includes R15,500 for emergency optometry, R15,500 for emergency dentistry and R765,000 terrorism cover.
  • R1,710 co-payment applies for each outpatient claim
Other:



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WELLNESS/PREVENTATIVE BENEFITS:
Custom Associate (and State provider for chronic)
Scheme Benefits: Notes and Links:
Flu vaccination:
  • Covered for under 18yrs and 60yrs+
Pneumonia vaccines:
  • Covered for 60yrs+
Biometric Screening:
  • Covered
Child Immunisation:
  • Covered
Pap Smear:
  • Covered for 15yrs+
Mammogram:
  • Covered for 38yrs+, every 2 years
PAS Test:
  • Covered for 40yrs+, every 1-5 years depending on age
HIV Test:
  • Covered for 15yrs+, every 5 years
Other:
  • Bone density scan: 50yrs+, every 3 years
  • Glaucoma test: 40yrs+, every 1-2 yrs, depending on age



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PROSTHETICS:
Custom Associate (and State provider for chronic)
Scheme Benefits: Notes and Links:
Overal Limit:
  • Internal: R46,600 per person per event, maximum 2 events per year
  • Intraocular lens: R5,500 per person, max 2 events per year
  • External, in-hospital: R21,900 per family
Sub-limits:
  • Intraocular lenses: R5,500 per person per event, maximum 2 events per year



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    Important!
  • Unless specified, assume that all benefits are paid are paid at 100% scheme rate
  • No limits or co-payments can apply to treatment of PMBs, which is always unlimited, although subject to strict protocols and scheme rules.
  • “Unlimited” benefits are still subject to authorisation, protocols and sublimits
  • Assume that all benefits need to be pre-authorised