Momentum Custom (any chronic provider) medical aid plan: 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)
Quick Overview
Main: Adult: Child:
Total Cost pm: R2,249 R1,806 R803

(Pay only for first 3)

Savings (per year):
  • No savings option on this plan
Gap (optional):
  • Varies. See below for specific recommendation for this plan.
In brief: See full benefits below

IN HOSPITAL PROCEDURES:
Custom (Any provider for chronic)
Scheme Benefits: Gap Benefits:
Specialists:
  • 100% scheme rate
  • Network specialists covered in full
  • You or gap cover pay the balance, if any
  • Gap tops this up to 500% scheme rate for in-hospital specialists, GPs and other medical professionals
  • Recommended for this plan: Plan Blue, R295pm per family where no member is older than 64yrs (otherwise, R435pm per family)
Hospital Choice:
  • Choose any hospital
  • No benefit
Specialised Radiology:
  • You or your gap pay R2,150 co-payment
  • In and out of hospital
  • Gap cover pays co-payments for procedures approved by medical aid
Supplementary Services: (Physio, etc) TBC
  • Gap tops this up to 500% scheme rate for in-hospital specialists, GPs and other medical professionals, for non-PMB treatment
  • No benefit for out-of-hospital services
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 as necessary, subject to medical aid approval for procedure
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
  • Gap cover pays co-payments for procedures approved by medical aid
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
  • Pays up to R20,000 per person per year for emergency medical treatment not paid for by medical aid
Other:
  • Gastroscopies and colonoscopies: Anaesthetists covered up to R450
  • Gap tops this up to 500% scheme rate for in-hospital specialists, GPs and other medical professionals
  • Sublimits increased as necessary
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)

No phone calls!
Our quote will include the right gap cover for this plan

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 (Any provider for chronic)
Scheme Benefits Gap benefits
Main: Adult: Child:
Savings /yr: No savings option on this plan
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, 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
Childcare:
  • 2 consults with paediatrician for children under 1yr
  • No extra benefit available
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
  • Co-payment paid, for authorised out of hospital MRI and CT Scans
Supplementary Services: (Physio, etc)
  • No benefit, unless PMB
  • No benefit

No phone calls!
Our quote will include the right gap cover for this plan

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MATERNITY BENEFITS:
Custom (Any provider for chronic)
Scheme Benefits Gap benefits
Hospital stay:
  • 100% scheme rate
  • Pays up to 500% scheme rate for specialists, GPs and other medical professionals, in-hospital only
Consultations:
  • 12 consults, paid by scheme
  • No benefit
Scans:
  • Unchanged
  • No benefit

No phone calls!
Our quote will include the right gap cover for this plan

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

No phone calls!
Our quote will include the right gap cover for this plan

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DENTISTRY:
Custom (Any provider for chronic)
Scheme Benefits Gap benefits
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
  • Pays shortfalls and co-payments for in-hospital dentistry treatment approved by scheme
Orthodontics:
  • You pay this out of pocket
  • No extra benefit available
Maxillo Facial Surgery:
  • See above
  • Pays shortfalls and co-payments for any non-PMB in-hospital dentistry treatment approved by scheme. (PMB are paid in full by scheme if you use DSP)

No phone calls!
Our quote will include the right gap cover for this plan

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MEDICATION:
Custom (Any provider for chronic)
Scheme Benefits Gap benefits
Chronic:
  • Unchanged
  • No benefit
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

No phone calls!
Our quote will include the right gap cover for this plan

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OPTOMETRY:
Custom (Any provider for chronic)
Scheme Benefits Gap benefits
Optometry:
  • Unchanged
  • Pays shortfalls and co-payments for any non-PMB in-hospital treatment approved by scheme. (PMBs are paid in full by scheme if you use DSP)

No phone calls!
Our quote will include the right gap cover for this plan

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MENTAL HEALTH:
Custom (Any provider for chronic)
Scheme Benefits Gap benefits
In-hospital:
  • R33,900 per person
  • Sublimits increased by R40,000 per event or medical condition
Out-of-hospital:
  • PMBs only
  • No benefit
Trauma:
  • No benefit
  • No benefit

No phone calls!
Our quote will include the right gap cover for this plan

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OTHER BENEFITS:
Custom (Any provider for chronic)
Scheme Benefits Gap benefits
General Appliances:
  • In-hospital: R5,950 per family
  • Out-of-hospital: No benefit
  • No benefit
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:
  • Unchanged
  • 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
  • No benefit

No phone calls!
Our quote will include the right gap cover for this plan

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WELLNESS/PREVENTATIVE BENEFITS:
Custom (Any provider for chronic)
Scheme Benefits Gap benefits
Flu vaccination:
  • Covered for under 18yrs and 60yrs+
  • No benefit
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

No phone calls!
Our quote will include the right gap cover for this plan

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PROSTHETICS:
Custom (Any provider for chronic)
Scheme Benefits Gap benefits
Overal Limit:
  • Sublimit increased by up to R150,000 per person
  • No benefit for procedures excluded by medical aid
Sub-limits:
  • Sublimit increased by up to R150,000 per person
  • No benefit for procedures excluded by medical aid

No phone calls!
Our quote will include the right gap cover for this plan


    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