Momentum Incentive (associate provider for chronic) medical aid plan: 2017

Out-of-hospital, scheme pays for some: specialised radiology (co-payment), maternity, preventative benefits. Limits apply. All else paid from savings or from out of pocket, unless PMB. Pay for maximum 3 children.

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IN HOSPITAL PROCEDURES:
Payout Rate for Specialists:
Overall Annual Limit (OAL):
Unlimited overall, with sub-limits
Contributions:
Main: Adult: Child:
Total Cost: R2,506 R2,010 R1,089
Children: Pay for maximum 3 children
Day-to-Day Benefit:
Out-of-hospital, scheme pays for some: specialised radiology (co-payment), maternity, preventative benefits. Limits apply. All else paid from savings or from out of pocket, unless PMB.
Main: Adult: Child:
(S) Savings: R3,007 R3,007 R2,412

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Hospital Choice:
  • Unlimited
Specialised Radiology:
  • Unlimited with a R2,030 co-payment
Supplementary Services: (Physio, etc)
Transplants:
  • Recipient: Unlimited
  • Donor R17,600 cadaver costs and R35,700 for live donor costs. Only covered if recipient is a member of the scheme
Co-payments:
  • Some in-hospital procedures: R1,200 co-payment applies
  • Specialised radiology: R2,030 co-payment
Alternatives to hospitals:
  • Medical rehabilitation, private nursing, hospice and step-down facilities: R44,400 per family. paid by scheme.

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OUT OF HOSPITAL BENEFITS:
GP consultations:
  • Paid from day-to-day benefit
Overall Annual Limit (OAL):
Unlimited overall, with sub-limits
Contributions:
Main: Adult: Child:
Total Cost: R2,506 R2,010 R1,089
Children: Pay for maximum 3 children
Day-to-Day Benefit:
Out-of-hospital, scheme pays for some: specialised radiology (co-payment), maternity, preventative benefits. Limits apply. All else paid from savings or from out of pocket, unless PMB.
Main: Adult: Child:
(S) Savings: R3,007 R3,007 R2,412

Compare with these plans:

Specialists consultations:
  • Paid from day-to-day benefit
Pathology:
  • Paid from day-to-day benefit
General radiology:
  • Paid from day-to-day benefit
Specialised radiology:
  • Unlimited with a R2,030 co-payment
Supplementary Services: (Physio, etc)
  • Paid from day-to-day benefit

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MATERNITY BENEFITS:
Hospital stay:
Overall Annual Limit (OAL):
Unlimited overall, with sub-limits
Contributions:
Main: Adult: Child:
Total Cost: R2,506 R2,010 R1,089
Children: Pay for maximum 3 children
Day-to-Day Benefit:
Out-of-hospital, scheme pays for some: specialised radiology (co-payment), maternity, preventative benefits. Limits apply. All else paid from savings or from out of pocket, unless PMB.
Main: Adult: Child:
(S) Savings: R3,007 R3,007 R2,412

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Consultations:
  • 12 consults, paid by scheme
Scans:
  • 2 x 2D scans, paid by scheme

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CANCER (ONCOLOGY):
Overall coverage (in and out of hospital):
  • R400,000 per person, with a 20% co-payment thereafter

Note: 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.
Overall Annual Limit (OAL):
Unlimited overall, with sub-limits
Contributions:
Main: Adult: Child:
Total Cost: R2,506 R2,010 R1,089
Children: Pay for maximum 3 children
Day-to-Day Benefit:
Out-of-hospital, scheme pays for some: specialised radiology (co-payment), maternity, preventative benefits. Limits apply. All else paid from savings or from out of pocket, unless PMB.
Main: Adult: Child:
(S) Savings: R3,007 R3,007 R2,412

Compare with these plans:

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DENTISTRY:
Dentistry:
  • Standard dentistry: One dental consult per year. Otherwise, from day-to-day benefit
  • In-hospital: maxillo-facial surgery, impacted wisdom teeth and general anaesthesia for children under 7yrs: R1,200 co-payment and surgeon accounts paid out-of-pocket
Overall Annual Limit (OAL):
Unlimited overall, with sub-limits
Contributions:
Main: Adult: Child:
Total Cost: R2,506 R2,010 R1,089
Children: Pay for maximum 3 children
Day-to-Day Benefit:
Out-of-hospital, scheme pays for some: specialised radiology (co-payment), maternity, preventative benefits. Limits apply. All else paid from savings or from out of pocket, unless PMB.
Main: Adult: Child:
(S) Savings: R3,007 R3,007 R2,412

Compare with these plans:

Orthodontics:
  • Paid from day-to-day benefit
Maxillo Facial Surgery: See "Specialised Dentistry" benefit, above

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MEDICATION:
Chronic:
  • PMB chronic: paid by scheme, from Network provider
  • non-PMBs chronic: additional 6 conditions covered, R8,800 per family
Overall Annual Limit (OAL):
Unlimited overall, with sub-limits
Contributions:
Main: Adult: Child:
Total Cost: R2,506 R2,010 R1,089
Children: Pay for maximum 3 children
Day-to-Day Benefit:
Out-of-hospital, scheme pays for some: specialised radiology (co-payment), maternity, preventative benefits. Limits apply. All else paid from savings or from out of pocket, unless PMB.
Main: Adult: Child:
(S) Savings: R3,007 R3,007 R2,412

Compare with these plans:
Acute (presrcibed) medication:
  • Paid from day-to-day benefit
Over-the-counter:
  • Paid from day-to-day benefit
Birth Control:
  • Paid from day-to-day benefit
On Discharge:
  • 7 days supply
Notes:

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OPTOMETRY:
Optometry:
  • Paid from day-to-day benefit
Overall Annual Limit (OAL):
Unlimited overall, with sub-limits
Contributions:
Main: Adult: Child:
Total Cost: R2,506 R2,010 R1,089
Children: Pay for maximum 3 children
Day-to-Day Benefit:
Out-of-hospital, scheme pays for some: specialised radiology (co-payment), maternity, preventative benefits. Limits apply. All else paid from savings or from out of pocket, unless PMB.
Main: Adult: Child:
(S) Savings: R3,007 R3,007 R2,412

Compare with these plans:

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MENTAL HEALTH:
In-hospital:
  • R32,600 per person
Overall Annual Limit (OAL):
Unlimited overall, with sub-limits
Contributions:
Main: Adult: Child:
Total Cost: R2,506 R2,010 R1,089
Children: Pay for maximum 3 children
Day-to-Day Benefit:
Out-of-hospital, scheme pays for some: specialised radiology (co-payment), maternity, preventative benefits. Limits apply. All else paid from savings or from out of pocket, unless PMB.
Main: Adult: Child:
(S) Savings: R3,007 R3,007 R2,412

Compare with these plans:


Out-of-hospital:
  • Paid from day-to-day benefit

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OTHER BENEFITS:
General Appliances:
  • In-hospital: R5,630 per family
  • Out-of-hospital: No benefit
Overall Annual Limit (OAL):
Unlimited overall, with sub-limits
Contributions:
Main: Adult: Child:
Total Cost: R2,506 R2,010 R1,089
Children: Pay for maximum 3 children
Day-to-Day Benefit:
Out-of-hospital, scheme pays for some: specialised radiology (co-payment), maternity, preventative benefits. Limits apply. All else paid from savings or from out of pocket, unless PMB.
Main: Adult: Child:
(S) Savings: R3,007 R3,007 R2,412

Compare with these plans:

1.1. Hearing Aids:
  • Paid from day-to-day benefit
1.2. Wheelchairs:
  • Paid from day-to-day benefit
Dialysis:
  • Unlimited, at Network chronic provider
HIV:
  • HIV related admissions: R62,500 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 Coverage:
  • R8 million international emergency cover
  • R1,470 co-payment applies for each outpatient claim
Other:
  • Cochlear implants: R144,500 per person
  • Trauma: Scheme covers some day-to-day benefits following certain traumatic events

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WELLNESS/PREVENTATIVE BENEFITS:
Flu vaccination:
  • Covered for under 18yrs and 60yrs+
Overall Annual Limit (OAL):
Unlimited overall, with sub-limits
Contributions:
Main: Adult: Child:
Total Cost: R2,506 R2,010 R1,089
Children: Pay for maximum 3 children
Day-to-Day Benefit:
Out-of-hospital, scheme pays for some: specialised radiology (co-payment), maternity, preventative benefits. Limits apply. All else paid from savings or from out of pocket, unless PMB.
Main: Adult: Child:
(S) Savings: R3,007 R3,007 R2,412

Compare with these plans:

Pneumonia vaccines:
  • Covered for 60yrs+
Back Rehabilitation Programme:
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

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PROSTHESIS:
Overal Limit:
Overall Annual Limit (OAL):
Unlimited overall, with sub-limits
Contributions:
Main: Adult: Child:
Total Cost: R2,506 R2,010 R1,089
Children: Pay for maximum 3 children
Day-to-Day Benefit:
Out-of-hospital, scheme pays for some: specialised radiology (co-payment), maternity, preventative benefits. Limits apply. All else paid from savings or from out of pocket, unless PMB.
Main: Adult: Child:
(S) Savings: R3,007 R3,007 R2,412

Compare with these plans:
Sub-limits:

    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