Momentum Extender (associate provider for chronic) medical aid plan: 2019

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Extender (Network provider for chronic)
2019 Costs:
Total Cost pm:

Main member:

R5,813

Adult:

R4,683

Child: (Pay only for first 3)

R1,673
Savings: R17,436 R14,052 R5,016
Self Payment Gap:
R3,364 R3,948 R1,184
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IN HOSPITAL PROCEDURES:
Extender (Network provider for chronic)
Scheme Benefits: Notes and Links:
Specialists:
  • Up to 200% scheme rate
  • Contracted Specialists: covered in full
  • You or gap cover pay the balance, if any
Gap Cover
  • Gap cover is available for this plan. Budget about R350 for a fully comprehensive gap cover that will increase the scheme rate to 500% and pay most co-payments and increase sublimits.
Hospital Choice:
  • Choose any hospital
Specialised Radiology:
  • You or your gap pay R2,150 co-payment
  • In and out of hospital
Supplementary Services: (Physio, etc) TBC
Transplants:
  • Recipient: Unlimited
  • Donor: R20,500 cadaver costs and R41,500 for live donor costs. Only covered if recipient is a member of the scheme
Co-payments:
  • Arthroscopies
  • Back and neck surgery
  • Carpal Tunnel release
  • Functional nasal and sinus procedures
  • Joint replacements
  • Laparoscopies
  • R3,000 co-payment
  • Gastroscopies,
  • Nail surgery,
  • Cystoscopies, colonoscopies, sigmoidoscopies,
  • Removing of extensive skin lesions
  • No co-payment if done in day-clinic or R3,000 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 co-payment and paid out of available day-to-day benefits
  • In-hospital: R3,000 co-payment
  • Otherwise, R1,500 co-payment for most admissions other than for maternity, motor accident and emergency treatment
  • Specialised radiology: R2,500 co-payment
Alternatives to hospitals:
  • Medical rehabilitation, private nursing, hospice and step-down facilities: R52,700 per family. Paid by scheme.
Casualty:
  • From day-to-day benefit, unless PMB
Other:
  • Gastroscopies and colonoscopies: Anaesthetists covered up to R950
Note:
  • Gap cover is an add-on to your medical aid, not a stand alone product
  • Gap cover has a maximum benefit payout of R150,000 per person per year for all gap benefits (except dread disease and premium waiver benefits which do not count towards the R150,000 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)
What next?
We will email you a quote for this and two other comparable plans. No phone calls.

Together with a financial advisor, we can help you with unpaid claims, findinging a gap cover, general advice, plan changes, cheaper options and more. FREE.

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.



OUT OF HOSPITAL BENEFITS (non-PMB):
Extender (Network provider for chronic)
Scheme Benefits Notes and Links:
Main Member: Adult: Child:
Savings /yr: R17,436 R14,052 R5,016
Self Payment Gap:
R3,364 R3,948 R1,184
Above Threshold: Once your savings are depleted, and you have paid the self payment gap, scheme will cover most out of hospital expenses at scheme rate, with sublimits for some benefits.
General info: 2019 Benefits coming November 9, 2018
GP consultations:
  • 1 GP consult per person, paid by scheme, every 1-5 years (frequency depends on age)
  • Otherwise, from day-to-day benefit, unless PMB
  • Network GPs: 100% scheme rate
  • Non-network GPs: 75% scheme rate
Childcare:
  • 2 consults with paediatrician for children under 1yr
Specialists consultations:
  • From day-to-day benefit, unless PMB
Pathology:
    From day-to-day benefit , unless PMB.
General radiology:
    From day-to-day benefit , unless PMB.
Specialised radiology:
  • Paid by scheme, with R2,250 co-payment, unless PMB
Supplementary Services: (Physio, etc)
  • From day-to-day benefit, unless PMB
What next?
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MATERNITY BENEFITS:
Extender (Network provider for chronic)
Scheme Benefits Notes and Links:
Hospital stay:
  • Contracted Specialists: covered in full, otherwise 200% scheme rate
Consultations:
  • 12 consults, paid by scheme
Scans:
  • 2 x 2D scans, paid by scheme
What next?
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CANCER (ONCOLOGY):
Extender (Network provider for chronic)
Scheme Benefits Notes and Links:
Overall coverage (in and out of hospital):
  • R500,000 per person, with a 20% co-payment thereafter
What next?
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DENTISTRY:
Extender (Network provider for chronic)
Scheme Benefits Notes and Links:
Standard Dentistry:
  • Standard dentistry: from day-to-day benefit
Specialised Dentistry:
  • Specialised dentistry: from day-to-day benefit, up to R12,800 per person and R33,500 per family
In-Hospital Dentistry:
  • In-hospital: maxillo-facial surgery, impacted wisdom teeth and general anaesthesia for children under 7yrs: R1,700 co-payment and surgeon accounts accumulate to threshold and specialised dentistry sub-limit
Orthodontics:
  • See above
Maxillo Facial Surgery:
  • See above
What next?
We will email you a quote for this and two other comparable plans. No phone calls.

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MEDICATION:
Extender (Network provider for chronic)
Scheme Benefits: Notes and Links:
Chronic:
  • Conditions covered:63 CDL conditions
  • Co-payment for non-formulary:
Acute (presrcibed) medication:
    Paid from day-to-day benefit, R16,700 per person and R31,500 per family
Over-the-counter:
  • From day-to-day benefit
  • , but does not accumulate to threshold
Birth Control:
  • From day-to-day benefit
On Discharge:
  • 7 days supply
Biological:
  • No benefit, unless PMB level of care
What next?
We will email you a quote for this and two other comparable plans. No phone calls.

Together with a financial advisor, we can help you with unpaid claims, findinging a gap cover, general advice, plan changes, cheaper options and more. FREE.

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OPTOMETRY:
Extender (Network provider for chronic)
Scheme Benefits: Notes and Links:
Optometry: From , up to R3,940 per person
Limit:day-to-day benefit
Consult:n/a
Frames:R2,150
Single lensesn/a
Bifocals:n/a
Multifocalsn/a
Contactsn/a
Refractive Surgery:n/a
Notes:n/a
What next?
We will email you a quote for this and two other comparable plans. No phone calls.

Together with a financial advisor, we can help you with unpaid claims, findinging a gap cover, general advice, plan changes, cheaper options and more. FREE.

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MENTAL HEALTH:
Extender (Network provider for chronic)
Scheme Benefits Notes and Links:
In-hospital: 2019 Benefits coming November 9, 2018
Out-of-hospital:
    Paid from day-to-day benefit, R18,900 per family
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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
What next?
We will email you a quote for this and two other comparable plans. No phone calls.

Together with a financial advisor, we can help you with unpaid claims, findinging a gap cover, general advice, plan changes, cheaper options and more. FREE.

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OTHER BENEFITS:
Extender (Network provider for chronic)
Scheme Benefits Notes and Links:
General Appliances:
  • In-hospital: R6,620 per family, paid by scheme
  • Out-of-hospital: R23,330 per family
  • No benefit
1.1. Hearing Aids:
  • R7,040, subject to "General Appliances" limit
1.2. Wheelchairs:
  • See "General Appliances" limit
Dialysis:
  • Unlimited, at Network chronic provider
HIV:
  • HIV related admissions: R69,200 per family
  • Since HIV is a PMB certain out-of-hospital benefits are automatically covered by all schemes according to protocols
Emergency Transport: Netcare 911
International Insurance:
  • R8.2 million international emergency cover. Includes R15,500 for emergency optometry, R15,500 for emergency dentistry and R765,000 terrorism cover.
  • R1,550 co-payment applies for each outpatient claim
Other:
  • Cochlear implants: R174,000 per person, maximum one event per year
What next?
We will email you a quote for this and two other comparable plans. No phone calls.

Together with a financial advisor, we can help you with unpaid claims, findinging a gap cover, general advice, plan changes, cheaper options and more. FREE.

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WELLNESS/PREVENTATIVE BENEFITS:
Extender (Network provider for chronic)
Scheme Benefits: Notes and Links:
Flu vaccination:
  • Covered for under 18yrs and 60yrs+
Pneumonia vaccines:
  • Covered for 60yrs+
Back Rehabilitation Programme: TBC
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
What next?
We will email you a quote for this and two other comparable plans. No phone calls.

Together with a financial advisor, we can help you with unpaid claims, findinging a gap cover, general advice, plan changes, cheaper options and more. FREE.

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PROSTHETICS:
Extender (Network provider for chronic)
Scheme Benefits: Notes and Links:
Overal Limit:
  • Internal: R65,900 per person per event, maximum 2 events per year
  • External: R22,900 per family
Sub-limits:
  • Intraocular lenses: R6,830 per person per event, maximum 2 events per year
What next?
We will email you a quote for this and two other comparable plans. No phone calls.

Together with a financial advisor, we can help you with unpaid claims, findinging a gap cover, general advice, plan changes, cheaper options and more. FREE.


    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