Momentum Ingwe C (associate provider) 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.

Ingwe Network C
2018 Costs:
Total Cost pm:

Main member:

R965

Adult:

R965

Child: (Pay for all)

R361
Savings Account:
  • No savings option on this plan
2019 Costs:
Total Cost pm:

Main member:

R1,062
(10.05%)

Adult:

R1,062

Child: (Pay for all)

R397
Savings (per year):
  • No savings option on this plan
Income band:
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In brief (2018): See full benefits below

IN HOSPITAL PROCEDURES:
Ingwe Network C
Scheme Benefits: Gap Benefits:
Specialists:
  • Up to 100% scheme rate
  • 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 anIngwe Network hospital, or pay a 30% co-payment if you voluntarily choose another hospital
  • No benefit, unless PMB
Specialised Radiology:
  • No benefit unless PMB. Then at State facilities only.
  • No benefit
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:
  • PMBs only, at State facilities
  • No extra benefit available (PMB benefits are paid in full by medical aid)
Co-payments:
  • N/A
  • N/A
Alternatives to hospitals:
  • Medical rehabilitation and step-down facilities: R12,500 per family
  • Private nursing and hospice: no benefit
  • No benefit, unless PMB
Casualty: 2019 Benefits coming November 9, 2018
  • Pays up to R20,000 per person per year for emergency medical treatment not paid for by medical aid
Other:
    Excluded:
  • Cardiovascular: 24-hour halter ECG, Blood transfusions, carotid angiograms, coronary angiogram, coronary angioplasty, plasmapheresis
  • ENT: arthroscopies, direct laryngoscopy, nasal scans and surgery, functional nasal and sinus surgery
  • General surgery: removal of minor skin lesions, laparoscopy, nail surgery, treatment of headache
  • Gastro-intestinal: colonoscopy, ERCP, gastroscopies, oesophagoscopy, sigmoidoscopy
  • Gynaecology: cervical laser ablation, hysteroscopy
  • Neurology: 48-hour halter EEG, electro-convulsive therapy, hyperbaric oxygen treatment for decompression sickness, myelogram
  • Obstetrics: amniocentesis
  • Oncology: hyperbaric oxygen for radiation necrosis
  • Opthalmology: catarct removal, pterygium removal, trabeculectomy, treatment of disease of conjunctiva
  • Orthopaedic: arthroscopy, back and neck surgery, conservative neck and back treatment, joint replacements, bunionectomy
  • Respiratory: bronchography, bronchoscopy, treatment of adult influenza, treatment of adult respiratory tract infections
  • Urology: cystoscopy
  • No benefit for exclusions
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):
Ingwe Network C
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:
  • Ingwe Primary Care Network: Unlimited
  • Non-network: 1 consult per person and 2 per family with R100 co-payment
  • No benefit, unless PMB
Childcare: 2019 Benefits coming November 9, 2018
  • No extra benefit available
Specialists consultations:
  • From Ingwe Primary Care Network: 2 consults per family limited to R1,000 per consult and R2,000 per family
  • No benefit, unless PMB
Pathology:
  • Some specific pathology covered by scheme, from Ingwe Active Primary Care network
  • No benefit, unless PMB
General radiology:
  • Some specific x-rays covered by scheme, from Ingwe Primary Care network
  • No benefit, unless PMB
Specialised radiology:
  • No benefit unless PMB. Then at State facilities only.
  • No benefit, unless PMB
Supplementary Services: (Physio, etc)
  • No benefit unless PMB. Then at State facilities only.
  • No benefit, unless PMB
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MATERNITY BENEFITS:
Ingwe Network C
Scheme Benefits Gap benefits
Hospital stay:
  • Complicated: R41,900
  • Uncomplicated: R28,600
  • Neonatal intensive care: R60,100, unless PMB
  • Elective C-sections: no benefit
  • Pays up to 500% scheme rate for specialists, GPs and other medical professionals, in-hospital only
  • In-hospital sublimits increased as necessary
Consultations:
  • 4 consults, paid by scheme
  • No benefit, unless PMB
Scans:
  • 2 growth scans
2019 Benefits coming November 9, 2018
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CANCER (ONCOLOGY):
Ingwe Network C
Scheme Benefits Gap benefits
Overall coverage (in and out of hospital):
  • PMBs only, at State facilities
  • No benefit, unless PMB
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DENTISTRY:
Ingwe Network C
Scheme Benefits Gap benefits
Standard Dentistry:
  • Standard dentistry: paid by scheme. Includes:
    • 1 consult per person
    • Fillings
    • Extractions
    • X-rays
Specialised Dentistry:
  • Specialised dentistry: no benefit
  • Pays shortfalls and co-payments for in-hospital dentistry treatment approved by scheme
In-Hospital Dentistry:
  • Maxilo-facial surgery: no benefit, unless PMB. Then at State facilities.
Orthodontics:
  • No benefit
Maxillo Facial Surgery:
  • No benefit unless PMB. Then at State facilities only.
  • 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:
Ingwe Network C
Scheme Benefits Gap benefits
Chronic:
  • Conditions covered:27 CDL conditions
  • All benefits from Ingwe Primary Care Network
  • No benefit, unless PMB
Acute (presrcibed) medication:
  • Some prescribed medication covered by scheme
  • 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:
Ingwe Network C
Scheme Benefits Gap benefits
Optometry:
Limit:Paid by scheme, every 2 years
Consult:1 per person
Frames:1 pair per person
Single lenses1 set as needed
Bifocals:1 set as needed
Multifocals
Contacts
Refractive Surgery:No benefit
Notes:
  • 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:
Ingwe Network C
Scheme Benefits Gap benefits
In-hospital: 2019 Benefits coming November 9, 2018
  • No benefit, unless PMB
Out-of-hospital:
  • No benefit unless PMB. Then at State facilities 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:
Ingwe Network C
Scheme Benefits Gap benefits
General Appliances:
  • In-hospital: R5,150 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:
  • PMBs only
  • , at State Facilities
2019 Benefits coming November 9, 2018
HIV:
  • Anti-retroviral treatment: R31,900 per family in hospital
  • HIV related admissions: R34,000 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:
  • No benefit, unless PMB
  • No benefit
Other: TBC
  • No benefit, unless PMB
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WELLNESS/PREVENTATIVE BENEFITS:
Ingwe Network C
Scheme Benefits Gap benefits
Flu vaccination:
  • Covered for under 18yrs and 60yrs+
  • No benefit
Pneumonia vaccines:
  • No benefit
  • 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:
  • No benefit
  • 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: 2019 Benefits coming November 9, 2018
  • No benefit
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PROSTHETICS:
Ingwe Network C
Scheme Benefits Gap benefits
Overal Limit:
  • PMBs only, at State Facilities
  • Sublimit increased by up to R150,000 per person
  • No benefit for procedures excluded by medical aid
Sub-limits: 2019 Benefits coming November 9, 2018
  • 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