Momentum Custom Associate (any chronic) medical aid plan: 2019

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Custom Associate (and any provider for chronic)
2019 Costs:
Total Cost pm:

Main member:

R2,113

Adult:

R1,667

Child: (Pay only for first 3)

R745
Savings (per year):
  • No savings option on this plan
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In brief (2018): See full benefits below

IN HOSPITAL PROCEDURES:
Custom Associate (and any provider for chronic)
Scheme Benefits: Notes and Links:
Specialists:
  • Up to 100% 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 a Network Hospital, or pay 30% co-payment if you voluntarily choose another 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: R18,600 cadaver costs and R37,700 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
  • 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
Alternatives to hospitals:
    Medical rehabilitation, private nursing, hospice and step-down facilities: R48,700 per family. Paid by scheme.
Casualty:
  • No benefit, unless PMB
Other:
  • Gastroscopies and colonoscopies: Anaesthetists covered up to R450
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.

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OUT OF HOSPITAL BENEFITS (non-PMB):
Custom Associate (and any provider for chronic)
Scheme Benefits Notes and Links:
Main Member: Adult: Child:
Savings /yr: No savings option on this plan
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, no benefit unless PMB
Childcare:
  • 2 consults with paediatrician for children under 1yr
Specialists consultations:
  • No benefit, unless PMB
Pathology:
  • No benefit, unless PMB
General radiology:
  • No benefit, unless PMB
Specialised radiology:
  • Paid by scheme, with R2,500 co-payment, unless PMB
Supplementary Services: (Physio, etc)
  • No benefit, unless PMB
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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MATERNITY BENEFITS:
Custom Associate (and any provider for chronic)
Scheme Benefits Notes and Links:
Hospital stay:
  • 100% scheme rate
Consultations:
  • 12 consults, paid by scheme
Scans:
  • 2 x 2D scans, paid by scheme
What next?
We will email you a quote for this and two other comparable plans. No phone calls.

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CANCER (ONCOLOGY):
Custom Associate (and any provider for chronic)
Scheme Benefits Notes and Links:
Overall coverage (in and out of hospital):
  • R300,000 per person, with a 20% co-payment thereafter
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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DENTISTRY:
Custom Associate (and any provider for chronic)
Scheme Benefits Notes and Links:
Standard Dentistry:
  • 1 consult per person paid by scheme
Specialised Dentistry:
  • Specialised dentistry: no benefit
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
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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MEDICATION:
Custom Associate (and any provider for chronic)
Scheme Benefits: Notes and Links:
Chronic:
  • Conditions covered:27 CDL conditions
  • Co-payment for non-formulary:
Acute (presrcibed) medication:
  • No benefit
Over-the-counter:
  • No benefit
Birth Control:
  • No 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:
Custom Associate (and any provider for chronic)
Scheme Benefits: Notes and Links:
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
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:
Custom Associate (and any provider for chronic)
Scheme Benefits Notes and Links:
In-hospital: 2019 Benefits coming November 9, 2018
Out-of-hospital:
  • PMBs only
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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:
Custom Associate (and any provider for chronic)
Scheme Benefits Notes and Links:
General Appliances:
  • In-hospital: R6,130 per family
  • Out-of-hospital: No benefit
  • No benefit
1.1. Hearing Aids:
  • No benefit
1.2. Wheelchairs:
  • 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
Emergency Transport: Netcare 911
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
Other: TBC
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:
Custom Associate (and any 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:
Custom Associate (and any provider for chronic)
Scheme Benefits: Notes and Links:
Overal Limit:
  • Internal: R44,400 per person per event, maximum 2 events per year
  • External: R21,500 per family
Sub-limits:
  • Intraocular lenses: R5,200 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