Momentum Custom (associate chronic) medical aid plan: 2019

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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.

Custom (Network for chronic)
2018 Costs:
Total Cost pm:

Main member:

R2,074

Adult:

R1,620

Child: (Pay only for first 3)

R753
Savings Account:
  • No savings option on this plan
2019 Costs:
Total Cost pm:

Main member:

R2,304
(11.09%)

Adult:

R1,800

Child: (Pay only for first 3)

R837
Savings (per year):
  • No savings option on this plan
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In brief (2018): See full benefits below

IN HOSPITAL PROCEDURES:
Custom (Network for chronic)
Scheme Benefits: Gap Benefits:
Specialists:
  • Up to 100% scheme rate
  • Contracted 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, unless PMB
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) 2019 Benefits coming November 9, 2018
  • 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:
  • Arthroscopies
  • Back and neck surgery
  • Carpal Tunnel release
  • Functional nasal and sinus procedures
  • Joint replacements
  • Laparoscopies
  • R4,500 co-payment
  • Gastroscopies,
  • Nail surgery,
  • Cystoscopies, colonoscopies, sigmoidoscopies,
  • Removing of extensive skin lesions
  • R550 co-payment if done in day-clinic or R4,500 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
  • In-hospital: R4,500 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
  • Gap cover pays co-payments for procedures approved by medical aid
Alternatives to hospitals:
    Medical rehabilitation, private nursing, hospice and step-down facilities: R48,700 per family. Paid by scheme.
  • No benefit, unless PMB
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)
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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 (Network for chronic)
Scheme Benefits Gap benefits
Main: Adult: Child:
Savings /yr: No savings option on this plan
General info: 2019 Benefits coming November 9, 2018
  • 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
  • No benefit, unless PMB
Childcare:
  • 2 consults with paediatrician for children under 1yr
  • No extra benefit available
Specialists consultations:
  • No benefit, unless PMB
  • No benefit, unless PMB
Pathology:
  • No benefit, unless PMB
  • No benefit, unless PMB
General radiology:
  • No benefit, unless PMB
  • No benefit, unless PMB
Specialised radiology:
  • Paid by scheme, with R2,500 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, unless PMB
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MATERNITY BENEFITS:
Custom (Network 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, unless PMB
Scans:
  • 2 x 2D scans, paid by scheme
2019 Benefits coming November 9, 2018
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CANCER (ONCOLOGY):
Custom (Network for chronic)
Scheme Benefits Gap benefits
Overall coverage (in and out of hospital):
  • R300,000 per person, with a 20% co-payment thereafter
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DENTISTRY:
Custom (Network for chronic)
Scheme Benefits Gap benefits
Standard Dentistry:
  • 1 consult per person paid by scheme
Specialised Dentistry:
  • Specialised dentistry: no benefit
  • Pays shortfalls and co-payments for in-hospital dentistry treatment approved by scheme
In-Hospital Dentistry:
  • In-hospital: maxillo-facial surgery, impacted wisdom teeth and general anaesthesia for children under 7yrs: R1,500 co-payment and surgeon accounts paid out-of-pocket
Orthodontics:
  • No benefit
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)
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MEDICATION:
Custom (Network for chronic)
Scheme Benefits Gap benefits
Chronic:
  • Conditions covered:27 CDL conditions
  • Co-payment for non-formulary:
  • No benefit, unless PMB
Acute (presrcibed) medication:
  • No benefit
  • No benefit, unless PMB
Over-the-counter:
  • No benefit
  • No benefit, unless PMB
Birth Control:
  • No benefit
  • No benefit, unless PMB
On Discharge:
  • 7 days supply
  • No benefit, unless PMB
Biological:
  • No benefit, unless PMB level of care
  • No benefit, unless PMB
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OPTOMETRY:
Custom (Network for chronic)
Scheme Benefits Gap benefits
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
  • 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)
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MENTAL HEALTH:
Custom (Network for chronic)
Scheme Benefits Gap benefits
In-hospital: 2019 Benefits coming November 9, 2018
  • Sublimits increased by R40,000 per event or medical condition
Out-of-hospital:
  • PMBs only
  • No benefit, unless PMB
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
  • No benefit, unless PMB
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OTHER BENEFITS:
Custom (Network for chronic)
Scheme Benefits Gap benefits
General Appliances:
  • In-hospital: R6,130 per family
  • Out-of-hospital: No benefit
  • No benefit
1.1. Hearing Aids:
  • No benefit
  • No benefit
1.2. Wheelchairs:
  • No benefit
  • No benefit
Dialysis:
  • Unlimited, at Network chronic provider
2019 Benefits coming November 9, 2018
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: Netcare 911
  • 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, unless PMB
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WELLNESS/PREVENTATIVE BENEFITS:
Custom (Network 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
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PROSTHETICS:
Custom (Network for chronic)
Scheme Benefits Gap benefits
Overal Limit:
  • Internal: R44,400 per person per event, maximum 2 events per year
  • External: R21,500 per family
  • Sublimit increased by up to R150,000 per person
  • No benefit for procedures excluded by medical aid
Sub-limits:
  • Intraocular lenses: R5,200 per person per event, maximum 2 events per year
  • Sublimit increased by up to R150,000 per person
  • No benefit for procedures excluded by medical aid
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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