Momentum Extender (state provider for chronic) medical aid plan: 2020

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Extender (State provider for chronic)
2020 Costs:
Total Cost pm:

Main member:

R5,713

Adult:

R4,691

Child:

R1,679
Savings: R17,136 R14,076 R5,040
Self Payment Gap:
R5,764 R5,924 R1,560
Above Threshold: Unlimited



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IN HOSPITAL PROCEDURES:
Extender (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:
  • Any hospital
Penalty for using other hospital:
  • n/a
Specialised Radiology:
  • R2,370 co-payment
Supplementary Services: (Physio, etc)
  • The Blue Plan gap cover will increase this to 500% scheme rate
Transplants:
  • Recipient: Unlimited
  • Donor: R21,500 cadaver costs and R43,600 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
  • R3,150 co-payment
  • Gastroscopies,
  • Nail surgery,
  • Cystoscopies, colonoscopies, sigmoidoscopies,
  • Removing of extensive skin lesions
  • No co-payment if done in day-clinic or R3,150 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: R3,150 co-payment
  • Otherwise, R1,500 co-payment for most admissions other than for maternity, motor accident and emergency treatment
  • Specialised radiology: R2,370 co-payment
Alternatives to hospitals:
    Medical rehabilitation, private nursing, hospice and step-down facilities: R55,000 per family. Paid by scheme.
Casualty:
  • From day-to-day 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):
Extender (State provider for chronic)
Scheme Benefits Notes and Links:
Main Member: Adult: Child:
Self Payment Gap:
R5,764 R5,924 R1,560
General info:
  • Our recommended gap cover does not pay out-of-hospital claims, unless it is for cancer treatment, dialysis, or MRI/CT scans
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
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:
  • R2,370 co-payment
  • Co-payment paid, for authorised out of hospital MRI and CT Scans
Supplementary Services: (Physio, etc)
  • From day-to-day benefit, unless PMB



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MATERNITY BENEFITS:
Extender (State provider for chronic)
Scheme Benefits Notes and Links:
Hospital stay:
  • Contracted Specialists: covered in full, otherwise 200% 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
  • 1 consult from nurse home visit, 6 weeks after above visit
Scans:
  • 2 x 2D scans, paid by scheme



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CANCER (ONCOLOGY):
Extender (State 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



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DENTISTRY:
Extender (State provider for chronic)
Scheme Benefits Notes and Links:
Standard Dentistry:
  • Standard dentistry: from day-to-day benefit
  • 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: from day-to-day benefit, up to R13,400 per person and R35,200 per family
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, withR1,500 co-payment and surgeon accounts paid from day-to-day benefit and accumulate towards threshold
Orthodontics:
  • See above
Maxillo Facial Surgery:
  • See above



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MEDICATION:
Extender (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
  • An additional 36 non-CDL conditions are covered on this plan, up to a R10,300 per family
  • Must use State provider
Acute (presrcibed) medication:
    Paid from day-to-day benefit, R17,500 per person and R33,100 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



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OPTOMETRY:
Extender (State provider for chronic)
Scheme Benefits: Notes and Links:
Optometry: From , up to R4,140 per person
Limit:day-to-day benefit
Consult:n/a
Frames:R2,260
Single lensesn/a
Bifocals:n/a
Multifocalsn/a
Contactsn/a
Refractive Surgery:n/a
Notes:n/a



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MENTAL HEALTH:
Extender (State provider for chronic)
Scheme Benefits Notes and Links:
In-hospital:
  • R37,900 per person, at preferred provider
Out-of-hospital:
    Paid from day-to-day benefit, R19,800 per family
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:
Extender (State provider for chronic)
Scheme Benefits Notes and Links:
General Appliances:
  • In-hospital: R6,950 per family, paid by scheme
  • Out-of-hospital: R24,500 per family
1.1. Hearing Aids:
  • R7,390, subject to "General Appliances" limit
1.2. Wheelchairs:
  • See "General Appliances" limit
Dialysis:
  • Unlimited, at any chronic provider
International Insurance:
  • R8.2 million international emergency cover. Includes R15,500 for emergency optometry, R15,500 for emergency dentistry and R765,000 terrorism cover.
  • R1,710 co-payment applies for each outpatient claim
Other:
  • Cochlear implants: R183,000 per person, maximum one event per year



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WELLNESS/PREVENTATIVE BENEFITS:
Extender (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:
Extender (State provider for chronic)
Scheme Benefits: Notes and Links:
Overal Limit:
  • Internal: R69,200 per person per event, maximum 2 events per year
  • Intraocular lens: R7,170 per person, max 2 events per year
  • External, in-hospital: R24,000 per family
Sub-limits:
  • Intraocular lenses: R7,170 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