Momentum Custom (any chronic provider) medical aid plan: 2017 vs 2018

View all plans in this scheme.
Please note that these benefits are still being updated as more information is made available to us. Always consult with your broker before making final decisions regarding your healthcare cover.

COSTS and OVERVIEW:
Custom (Any provider for chronic)
2018 costs In brief:
What’s new in 2018?
Main: Adult: Child:
Cost 2018: R2,249 R1,806 R803
Cost 2017: (R2,059) (R1,653) (R735)
Gap (optional): KaeloXelus: R350 per family
(R600 per family if anyone is 60yrs+)
Overal Limit: Unlimited
PMBs: Day-to-day expenses for PMBs (eg. cancer) are always paid for by the scheme, according to protocols. Find out more
Savings: No savings option on this plan
Children: Pay for maximum 3 children
  • There are no major changes to this plan in 2018, other than the usual monetary increases in premiums, benefits and co-payments

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Avoid bills! Get up to: 800% scheme rate;  R12,800 per ER visit; unlimited cancer cover;  

co-payments paid and cash payout for hospital stay. R350pm per family


IN HOSPITAL PROCEDURES:
Custom (Any provider for chronic)
2017 v 2018 benefits Gap benefits Notes
Payout Rate for Specialists: Fusion Gap:
  • Up to 600% scheme rate for specialists and other providers
  • In case of admission related to accident:
    -R300 per day, for days 1-13
    -R600 per day for days 14-20
    -R1,200 per day for days 21-30
  • R350pm per family. More Info or download application below.

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Hospital Choice:
  • Unlimited
  • N/A
Specialised Radiology:
  • Co-payment: R2,150, unless PMB
  • Sublimit: none
  • Rate: 100% scheme rate
  • In and out of hospital
Fusion Gap:
  • Gap covers co-payments for most scopes and a defined list of other procedures, incl MRIs etc See full list
Supplementary Services: (Physio, etc) TBC Fusion Gap:
  • Up to 600% scheme rate for specialists and other providers
Transplants:
  • Recipient: Unlimited
  • Donor R18,600 cadaver costs and R37,700 for live donor costs. Only covered if recipient is a member of the scheme
  • Sublimit increased by R40,000 per event or medical condition, unlimited for the year
Co-payments:
    Gastroscopies, nail surgery, cystoscopies, colonoscopies, sigmoidoscopies, removing of extensive skin lesions: R550 co-payment if done in day-clinic Otherwise, R1,300 co-payment for most admissions other than for maternity, motor accident and emergency treatment Specialised radiology: R2,150 co-payment
Fusion Gap:
  • Gap covers co-payments for most scopes and a defined list of other procedures, incl MRIs etc See full list
Alternatives to hospitals:
    Medical rehabilitation, private nursing, hospice and step-down facilities: R46,400 per family. Paid by scheme.
  • No benefit
Casualty:
  • No benefit, unless PMB
  • Casualty costs not covered by medical aid, in case of emergency treatment: R12,800 per incident. Cover also applies to costs covered by savings account.
Other:
  • Gastroscopies and colonoscopies: Anaesthetists covered up to R450
  • Up to 500% of scheme rate
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OUT OF HOSPITAL BENEFITS:
Custom (Any provider for chronic)
2017 v 2018 benefits Gap benefits Notes
GP consultations:
  • 1 GP consult per person, paid by scheme, every 1-5 years (frequency depends on age)
  • Otherwise, no benefit unless PMB
  • Out of hospital treatment for conditions that are PMBs is always paid for by the scheme (not out of savings), but according to protocols
  • No benefit


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Childcare:
  • 2 consults with paediatrician for children under 1yr
  • No benefit
Specialists consultations:
  • No benefit, unless PMB
  • No benefit
Pathology:
  • No benefit, unless PMB
  • No benefit
General radiology:
  • No benefit, unless PMB
  • No benefit
Specialised radiology:
  • Paid by scheme, with R2,150 co-payment, unless PMB
  • No benefit
Supplementary Services: (Physio, etc)
  • No benefit, unless PMB
  • No benefit
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MATERNITY BENEFITS:
Custom (Any provider for chronic)
2017 v 2018 benefits Gap benefits Notes
Hospital stay:
  • Unchanged
  • Premature birth, more than 6 weeks:R12,000 lump payment
  • In case of admission related to premature birth:
    • R300 per day, for days 1-13
    • R600 per day for days 14-20
    • R1,200 per day for days 21-30

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Consultations:
  • Unchanged
  • No benefit
Scans:
  • Unchanged
  • No benefit
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CANCER (ONCOLOGY):
Custom (Any provider for chronic)
2017 v 2018 benefits Gap benefits Notes
Overall coverage (in and out of hospital):
  • R300,000 per person, with a 20% co-payment thereafter
  • Up to additional 500% of scheme rate to cover shortfall for specialists
  • Full cover for the 20% co-payment
All oncology benefits are assessed on a case-by-case basis, and are subject to protocols, preferred providers and scheme rules. Benefit covers out-of-hospital treatment too, like chemotherapy.
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DENTISTRY:
Custom (Any provider for chronic)
2017 v 2018 benefits Gap benefits Notes
Dentistry:
  • 1 consult per person paid by scheme
  • In-hospital: maxillo-facial surgery, impacted wisdom teeth and general anaesthesia for children under 7yrs: R1,300 co-payment and surgeon accounts paid out-of-pocket
  • Dental reconstruction due to due to trauma or oncology treatment: R40,000 per event
  • Full cover for in-hospital co-payments

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Orthodontics:
  • Unchanged
  • No benefit
Maxillo Facial Surgery:
  • See above
  • Dental reconstruction as result of trauma or oncology: R40,000 per event

Avoid bills! Get up to: 800% scheme rate;  R12,800 per ER visit; unlimited cancer cover;  

co-payments paid and cash payout for hospital stay. R350pm per family

MEDICATION:
Custom (Any provider for chronic)
2017 v 2018 benefits Gap benefits Notes
Chronic:
  • Unchanged
  • No benefit

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Acute (presrcibed) medication:
  • Unchanged
  • No benefit
Over-the-counter:
  • Unchanged
  • No benefit
Birth Control:
  • No benefit
  • No benefit
On Discharge:
  • Unchanged
  • No benefit
Biological:
  • No benefit
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OPTOMETRY:
Custom (Any provider for chronic)
2017 v 2018 benefits Gap benefits Notes
Optometry:
  • Unchanged
  • No benefit

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MENTAL HEALTH:
Custom (Any provider for chronic)
2017 v 2018 benefits Gap benefits Notes
In-hospital:
  • R33,900 per person
  • Sublimits increased by R40,000 per event or medical condition

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Out-of-hospital:
  • PMBs only
  • No benefit
Trauma:
  • No benefit
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OTHER BENEFITS:
Custom (Any provider for chronic)
2017 v 2018 benefits Gap benefits Notes
General Appliances:
  • In-hospital: R5,950 per family
  • Out-of-hospital: No benefit
  • No benefit

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1.1. Hearing Aids:
  • Unchanged
  • No benefit
1.2. Wheelchairs:
  • No benefit
  • No benefit
Dialysis:
  • Unlimited
HIV:
  • HIV related admissions: R65,900 per family
  • Since HIV is a PMB certain out-of-hospital benefits are automatically covered by all schemes according to protocols
  • No benefit
Emergency Transport:
  • No benefit
International Insurance:
  • R7.66 million international emergency cover. Includes R15,500 for emergency optometry, R15,500 for emergency dentistry and R765,000 terrorism cover.
  • R1,550 co-payment applies for each outpatient claim
  • No benefit
Other: TBC
  • Death or permanent disability: R12,000. If cause of death was accidental: R24,000.
  • If Principal member of medical aid passes away or becomes disabled: Medical aid contributions will be paid for six months, up to R4,400 per month. Gap premium is also waived for 6 months
  • In event of vehicle accident where policy holder was not at fault: Gap will provide all legal assistance, fully covered.
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WELLNESS/PREVENTATIVE BENEFITS:
Custom (Any provider for chronic)
2017 v 2018 benefits Gap benefits Notes
Flu vaccination:
  • Covered for under 18yrs and 60yrs+
  • No benefit

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Pneumonia vaccines:
  • Covered for 60yrs+
  • No benefit
Back Rehabilitation Programme: TBC
  • No benefit
Biometric Screening:
  • Covered
  • No benefit
Child Immunisation:
  • Covered
  • No benefit
Pap Smear:
  • Covered for 15yrs+
  • No benefit
Mammogram:
  • Covered for 38yrs+, every 2 years
  • No benefit
PAS Test:
  • Covered for 40yrs+, every 1-5 years depending on age
  • No benefit
HIV Test:
  • Covered for 15yrs+, every 5 years
  • No benefit
Other:
  • Bone density scan: 50yrs+, every 3 years
  • Glaucoma test: 40yrs+, every 1-2 yrs, depending on age
  • No benefit

Avoid bills! Get up to: 800% scheme rate;  R12,800 per ER visit; unlimited cancer cover;  

co-payments paid and cash payout for hospital stay. R350pm per family

2017 v 2018 benefits Gap benefits Notes
Overal Limit:
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Sub-limits:
  • An additional R40,000 per sublimit, per event

    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