benefit option overview 2017

Transcription

1 benefit option overview 2017

2 index 2 Benefit Structure Make the right choice Choice of options: 6 Ingwe Option 7 Access Option 8 Custom Option 9 Incentive Option 10 Extender Option 11 Summit Option choice Momentum Health strives to offer you good value for money by combining flexibility with comprehensive cover, because it is important to match your family s healthcare needs. Use the following guide to find the option that best matches your needs. Healthcare expenses involve more than just the cost of your stay in hospital, it could be the cost of chronic medication (like pills to lower high blood pressure), day-to-day expenses (like visiting your GP), and/or emergency care. The option that you choose will determine how much you will pay, and how much cover you will have for the different types of healthcare expenses. You need to choose the option that best fits both your wallet and your healthcare needs. 12 Benefit 14 List of s 16 Exclusions This Benefit Option Overview provides a summary of the Momentum Health 2017 benefits. If you need more information, please speak to your Financial Adviser, contact our call centre on or visit our website at Scheme Rules will always take precedence and are available by submitting a request on our website at Momentum Health is registered in terms of the Medical Schemes Act No 131 of 1998 Member call centre Fraud hotline for queries for claims Website member@momentumhealth.co.za claims@momentumhealth.co.za Postal address PO Box 2338, Durban, 4000

3 Benefit Structure Ingwe Option Access Option The provides cover for hospitalisation and certain out-of-hospital procedures that can safely be performed in a doctor s room, registered day clinic or outpatient facility, provided treatment is clinically appropriate and has been pre-authorised. Specialists covered up to 100% of Momentum Health Rate accounts Limited to R per family per year choice hospital, Ingwe hospitals* or State hospitals Specialists covered up to 100% of Momentum Health Rate accounts No overall annual limit Access hospitals* The covers certain lifethreatening conditions that need ongoing treatment. The includes cover for the 26 Chronic Disease List (CDL) conditions, which form part of the Prescribed Minimum Benefits (PMBs). Chronic benefits are subject to registration and approval. annual limit entry-level Care s** or s** annual limit entry-level Access s** This benefit provides for day-to-day medical expenses, such as GP visits, prescribed medication, etc. Primary care (such as GP visits, prescribed medicine, etc.) Secondary care (Specialist visits) Care s** or s** Primary care (such as GP visits, prescribed medicine, etc.) Secondary care (Specialist visits) Access s** You have the choice of adding more day-today cover through the HealthSaver +. Benefit + You can choose to make use of additional products (like HealthSaver) available from Momentum Group (Momentum), a division of MMI Group Limited, to seamlessly enhance your medical aid. Momentum is not a medical scheme, and is a separate entity from Momentum Health * View a list of these hospitals on page 14 ** View a list of these s on Benefits are paid by the Scheme up to a maximum Rand amount per benefit, provided you notify us before using the benefit. On the Ingwe and Access Options, Benefits are only available from Ingwe or Access s. The encourages health awareness, enhances quality of life and gives peace of mind through preventative care, early detection, a leading maternity programme, management of certain diseases, health education and advice and emergency cover. 2 3

4 Custom Option Incentive Option Extender Option Summit Option specialists covered in full Other specialists covered up to 100% of Momentum Health Rate accounts No overall annual limit R1 200 co-payment choice or hospitals* specialists covered in full Other specialists covered up to 200% of Momentum Health Rate accounts No overall annual limit choice or hospitals* specialists covered in full Other specialists covered up to 200% of Momentum Health Rate accounts No overall annual limit choice or hospitals* specialists covered in full Other specialists covered up to 300% of Momentum Health Rate accounts No overall annual limit hospital annual limit : Core : Entry-level State: State ( GP and any pharmacy), ** (Selected preferred GPs and Medipost Courier pharmacy for chronic medication), or State facilities (medical management including doctor, pharmacy, blood tests, x-rays, etc.) annual limit. Additional 6 conditions limited to R8 800 per family : Standard : Entry-level State: State ( GP and any pharmacy), ** (Selected preferred GPs and Medipost Courier pharmacy for chronic medication), or State facilities (medical management including doctor, pharmacy, blood tests, x-rays, etc.) annual limit. Additional 36 conditions limited to R8 800 per family : Extended : Entry-level State: State ( GP and any pharmacy), ** (Selected preferred GPs and Medipost Courier pharmacy for chronic medication), or State facilities (medical management including doctor, pharmacy, blood tests, x-rays, etc.) annual limit. Additional 36 conditions accumulate to the overall day-to-day limit of R per beneficiary Comprehensive Provider Freedom-of-choice Add the HealthSaver+ to provide cover for your day-to-day healthcare needs Savings 10% of total contribution, subject to Savings if available Savings 25% of total contribution plus Extended Cover or (Members who have chosen as their chronic must use an GP for GP consultations) Paid from risk benefit, subject to overall day-today limit of R per beneficiary. This is a combined limit incorporating both dayto-day cover and cover for the 36 additional chronic conditions. Freedom-of-choice 4 5

5 Ingwe Option Overview Access Option Overview Choice of hospital Chronic and Day-to-day Specialists covered up to 100% of the Momentum Health Rate accounts the rate agreed upon with the hospital group Limited to R per family per year hospital, Ingwe hospitals or State hospitals tonsillectomy or grommets 26 conditions covered Primary care benefits such as medicine, GP visits, basic dentistry, basic radiology and basic pathology Care or Covers benefits such as Health Assessments, dental examinations, routine GP check-ups, pap smears, etc. Maternity benefit: 4 antenatal visits and 2 growth scans Chronic and Day-to-day Specialists covered up to 100% of the Momentum Health Rate accounts the rate agreed upon with the hospital group No overall annual limit Access hospitals tonsillectomy or grommets 26 conditions covered Primary care benefits such as medicine, GP visits, basic dentistry, basic radiology and basic pathology Access Covers benefits such as Health Assessments, dental examinations, routine GP check-ups, pap smears, etc. Maternity benefit: 4 antenatal visits and 2 growth scans Choose your monthly income Choose your s Your s Chronic Day-to-day Chronic Day-to-day State Care Care R335 R670 R545 R880 R1 090 R1 300 Access Access Primary Care Access Primary Care R1 842 R3 684 R2 394 R4 236 R4 788 R5 340 <= R650 Ingwe Care Care R335 R670 R545 R880 R1 090 R1 300 R335 R670 R545 R880 R1 090 R1 300 All children are charged for State Care Care R560 R1 120 R862 R1422 R1 724 R2 026 R651 - R6 100 Ingwe Care Care R701 R1 402 R1 022 R1 723 R2 044 R2 365 R911 R1 822 R1 253 R2 164 R2 506 R2 848 State Care Care R641 R1282 R950 R1 591 R1 900 R2 209 R R8 200 Ingwe Care Care R892 R1 784 R1 226 R2 118 R2 452 R2 786 R1 273 R2 546 R1 658 R2 931 R3 316 R3 701 State Care Care R748 R1 496 R1 072 R1 820 R2 144 R2 468 R R Ingwe Care Care R1 241 R2 482 R1 606 R2 847 R3 212 R3 577 R1 734 R3 468 R2 140 R3 874 R4 280 R4 686 State Care Care R1 291 R2 582 R1 680 R2 971 R3 360 R3 749 R Ingwe Care Care R1 758 R3 516 R2 276 R4 034 R4 552 R5 070 R2 225 R4 450 R2 871 R5 096 R5 742 R6 388 All children are charged for 6 7

6 Custom Option Overview Incentive Option Overview Choice of hospital specialists covered in full Other specialists covered up to 100% of the Momentum Health Rate accounts the rate agreed upon with the hospital group No overall annual limit R1 200 co-payment, except for motor vehicle accidents, maternity confinements and emergency treatment An additional co-payment may apply to Specialist Referral Procedures or hospitals tonsillectomy, angiograms and hysteroscopies 26 conditions covered Choice of Chronic Provider, or State You can add HealthSaver + to provide cover for your day-to-day healthcare expenses, such as GP visits, prescribed medicine, etc. Covers benefits such as Health Assessments, dental examinations, routine GP check-ups, pap smears Maternity benefit: 12 antenatal visits, 2 pregnancy scans and 2 paediatrician visits in your child s first year Choice of hospital specialists covered in full Other specialists covered up to 200% of the Momentum Health Rate accounts the rate agreed upon with the hospital group No overall annual limit Co-payments may apply to Specialist Referral Procedures or hospitals Choice of Chronic Provider, or State tonsillectomy, angiograms and hysteroscopies 26 conditions covered - no annual limit 6 additional conditions covered, subject to limit of R8 800 per family per year 10% of your total contribution is available in a Savings account to cover your day-to-day expenses, such as GP visits, prescribed medicine, etc. Covers benefits such as Health Assessments, dental examinations, routine GP check-ups, pap smears Maternity benefit: 12 antenatal visits, 2 pregnancy scans and 2 paediatrician visits in your child s first year + HealthSaver is a complementary product offered by Momentum Choose your s Choose your s Chronic Chronic R1 742 R3 116 R2 356 R3 730 R4 344 R4 958 R2 529 R4 563 R3 473 R5 507 R6 451 R7 395 R1 573 R2 792 R2 129 R3 348 R3 904 R4 460 R2 323 R4 171 R3 206 R5 054 R5 937 R6 820 State R1 266 R2 223 R1 714 R2 671 R3 119 R3 567 State R1 700 R3 033 R2 359 R3 692 R4 351 R5 010 R2 059 R3 712 R2 794 R4 447 R5 182 R5 917 R2 794 R5 064 R3 883 R6 153 R7 242 R8 331 R1 899 R3 382 R2 588 R4 071 R4 760 R5 449 R2 506 R4 516 R3 490 R5 500 R6 484 R7 468 State R1 610 R2 825 R2 200 R3 415 R4 005 R4 595 State R2 088 R3 734 R2 914 R4 560 R5 386 R6 212 Maximum of 3 children charged for Maximum of 3 children charged for 8 9

7 Extender Option Overview Summit Option Overview specialists covered in full Other specialists covered up to 200% of the Momentum Health Rate accounts the rate agreed upon with the hospital group No overall annual limit Co-payments may apply to Specialist Referral Procedures Choice of hospital or hospitals Choice of chronic, or State tonsillectomy, angiograms and hysteroscopies 26 conditions covered - no annual limit 36 additional conditions covered, subject to limit of R8 800 per family per year 25% of your total contribution is available in a Savings account to cover day-to-day expenses, such as GP visits, prescribed medicine etc. You also have access to the Extended Cover benefit once your day-to-day claims have reached the Threshold Threshold levels: Principal member R Adult: R Child: R5 100 Covers benefits such as Health Assessments, dental examinations, routine GP check-ups, pap smears Maternity benefit: 12 antenatal visits, 2 pregnancy scans and 2 paediatrician visits in your child s first year specialists covered in full Other specialists covered up to 300% of the Momentum Health Rate accounts the rate agreed upon with the hospital group No overall annual limit hospital tonsillectomy, angiograms and hysteroscopies 26 conditions covered - no annual limit 36 additional conditions covered, subject to overall day-to-day limit Covered from risk benefit, subject to overall day-to-day limit of R per beneficiary and certain sub-limits Chronic and Day-to-day Freedom-of-choice Covers benefits such as Health Assessments, dental examinations, routine GP check-ups, pap smears Maternity benefit: 12 antenatal visits, 2 pregnancy scans and 2 paediatrician visits in your child s first year Choose your s Your s Chronic Chronic Day-to-day R4 671 R8 399 R R9 864 R R Freedom-of-choice Freedom-of-choice R7 637 R R9 391 R R R R4 304 R7 737 R R9 089 R R State R3 732 R6 537 R R7 686 R8 835 R9 984 Maximum of 3 children charged for R5 308 R9 543 R R R R R4 776 R8 589 R R R R State R4 309 R7 816 R R9 139 R R Maximum of 3 children charged for 10 11

8 Health Platform Benefit Benefits are paid by the Scheme up to a maximum Rand amount per benefit, provided you notify us before using the benefit. You can pre-notify by contacting the member call centre on , logging on to or via the mobi app. On the Ingwe and Access Options, Benefits are only available from Ingwe or Access s. Please note * On the Custom, Incentive and Extender Options, if you choose as your chronic, a 30% co-payment will apply if you do not use an GP for the GP consultations ** The cholesterol test is covered if Health Assessment results indicate a total cholesterol of 6 mmol/l and above *** The blood sugar test is covered if Health Assessment results indicate blood sugar levels are 11 mmol/l and above Benefit Who? How often? Early detection tests Health Assessment (pre-notification not required): Body Mass Index, Blood pressure test, Cholesterol (finger prick test) and Blood sugar test (finger prick test) All principal members and adult beneficiaries Once a year Dental consultation (incl. sterile tray and gloves) All beneficiaries Once a year Pap smear (pathologist) Women 15 and older Once a year Pap smear consultation (GP) Women 15 and older Once a year Pap smear consultation (GP* or gynaecologist) Women 15 and older Once a year Mammogram Women 38 and older Once every 2 years DEXA bone density scan (radiologist, GP* or specialist) General physical examination (GP* consultation) Beneficiaries 50 and older Once every 3 years Ingwe Access Custom Incentive Extender Summit Beneficiaries 21 to 29 Once every 5 years Beneficiaries 30 to 59 Once every 3 years Beneficiaries 60 to 69 Once every 2 years Beneficiaries 70 and older Once a year Prostate specific antigen (pathologist) Men 40 to 49 Once every 5 years Men 50 to 59 Once every 3 years Men 60 to 69 Once every 2 years Men 70 and older Once a year Cholesterol test (pathologist)** Principal members and adult beneficiaries Once a year Blood sugar test (pathologist)*** Principal members and adult beneficiaries Once a year Glaucoma test Beneficiaries 40 to 49 Once every 2 years Beneficiaries 50 and older Once a year HIV test (pathologist) Beneficiaries 15 and older Once every 5 years Preventative care Baby immunisations (On Ingwe and Access, available at nearest State baby clinic) Children up to age 6 As required by the Department of Health Flu vaccines Beneficiaries under 18 Once a year Beneficiaries 60 and older High-risk beneficiaries Tetanus diphtheria injection All beneficiaries As needed Pneumococcal vaccine Beneficiaries 60 and older Once a year High-risk beneficiaries Maternity programme (subject to registration on the Maternity Management Programme between 8 and 20 weeks of pregnancy) Antenatal visits (Midwives, GP* or gynaecologist) Urine tests (dipstick) Maternity scans Paediatrician visits Disease management programmes Diabetes, Hypertension, HIV/Aids, Oncology, Drug and alcohol rehabilitation, Chronic renal failure, Organ transplants, Cholesterol Health line Women registered on the programme Women registered on the programme Women registered on the programme Women registered on the programme Women registered on the programme Babies up to 12 months registered on the programme All beneficiaries registered on the appropriate programme 4 visits 12 visits Included in antenatal visits 2 growth scans 2 pregnancy scans 2 visits in baby s first year As needed 24-hour emergency health advice All beneficiaries As needed Emergency evacuation Emergency evacuation in South Africa by Netcare 911 All beneficiaries In an emergency International evacuation by ISOS All beneficiaries In an emergency International emergency cover by ISOS Ingwe: Not covered Access: R3.38 million Custom: R7.66 million Incentive: R8 million Extender: R8.22 million Summit: R9.01 million This benefit includes R for emergency optometry, R for emergency dentistry and R terrorism cover, on all options, except Ingwe. A R1 470 co-payment per out-patient claim Per beneficiary per 90-day journey In an emergency 12 13

9 List of hospitals Members on the Ingwe Option can choose between hospital, Ingwe hospitals or State hospitals Members on the Access Option need to use Access hospitals Members on the Custom, Incentive and Extender Options can choose between or hospitals Eastern Cape Life Beacon Bay Beacon Bay - East Isivivana Private Humansdorp East London Private East London Settlers Private Grahamstown Greenacres Greenacres - Port Elizabeth New Mercantile Korsten - Port Elizabeth Port Alfred Port Alfred Hunterscraig Psychiatric Port Elizabeth St Georges Port Elizabeth Queenstown Private Queenstown St. Dominic s Southernwood - East London St James Operating Theatres Southernwood - East London St Marks Clinic Southernwood - East London Cuyler Uitenhage St Mary s Private Umtata Free State Hoogland Mediclinic Bethlehem Bloemfontein Eye Bloemfontein Pasteur Bloemfontein Pelonomi Private Bloemfontein Rosepark Fichardtpark - Bloemfontein Welkom Mediclinic Welkom Bloemfontein Mediclinic Bloemfontein Universitas Private Bloemfontein Kroon Kroonstad Vaalpark Medical Centre Sasolburg Gauteng Ingwe Access s Clinton Alberton Union Alberton Femina Clinic Arcadia Muelmed Arcadia Pretoria Heart Arcadia Netcare Rehabilitation Auckland Park Bedford Gardens Private Bedfordview Glynnview Benoni The Glynnwood Benoni Linmed Benoni Rand Clinic Berea Birchmed Day Clinic Birchleigh Sunward Park Boksburg Dalview Clinic Brakpan Brooklyn Surgical Centre Brooklyn Sandton Mediclinic Bryanston Unitas Centurion Mayo Clinic Constantia Kloof Bougainville Private Daspoort Gauteng (continued) Ingwe Access s Wilgers Die Wilgers Kloof Erasmuskloof Faerie Glen Faerie Glen Flora Clinic Florida Fourways Fourways Groenkloof Groenkloof Suikerbosrand Clinic Heidelberg Medgate Day Clinic Helderkruin Bagleyston Day Clinic Highlands Park Lane Clinic Houghton Akasia Clinic Karen Park Arwyp Medical Centre Kempton Park New Kensington Clinic Kensington Bellstreet Krugersdorp Krugersdorp Private Krugersdorp Pinehaven Private Krugersdorp Protea Clinic Krugersdorp Lenmed Clinic Limited Lenasia Eugene Marais Les Marais Linksfield Park Clinic Linksfield Legae Private Clinic Mabopane Garden City Clinic Mayfair Carstenhof Clinic Midrand Waterfall City Midrand Montana Private Montana Park Pretoria East Private Moreleta Park Morningside Mediclinic Morningside Jakaranda Muckleneuck Mulbarton Mulbarton Riverfield Lodge Nietgedacht Rosewood Clinic Orange Grove The Donald Gordon Parktown Brenthurst Clinic Parktown Milpark Parktown Pretoria North Surgical Centre Pretoria North Roseacres Clinic Primrose Olivedale Clinic Randburg Robinson Randfontein Moot General Rietfontein Constantia Clinic Roodepoort Wilgeheuwel Roodepoort Rosebank Clinic Rosebank Genesis Clinic Saxonwold Clinix Tshepo Soweto Springs Parkland Clinic Springs N17 Private Springs St Mary s Womens Clinic Springs Sunninghill Sunninghill Medforum Sunnyside Pretoria Gynaecology Sunnyside Emfuleni Mediclinic Vanderbijlpark Vereeniging Mediclinic Vereeniging Clinix Naledi Vereeniging Kwazulu-Natal Kingsway Amanzimtoti Alberlito Ballito Entabeni Berea Chatsmed Garden Chatsworth City Durban Durdoc Clinic Durban Maxwell Clinic Durban St Augustines Durban Empangeni Garden Clinic Empangeni Hillcrest Private Hillcrest Hilton Private Hilton Howick Private Howick Isipingo Isipingo La Verna Ladysmith Margate Private Margate Newcastle Private Newcastle Parklands Overport Mount Edgecombe Phoenix Midlands Medical Centre Pietermaritzburg Pietermaritzburg Mediclinic Pietermaritzburg St Annes Pietermaritzburg The Crompton Pinetown Hibiscus Port Shepstone The Bay Richards Bay Victoria Tongaat Umhlanga Umhlanga Westville Westville Limpopo Lephalale Mediclinic Lephalale Limpopo Mediclinic Polokwane Pholoso Private Polokwane Tzaneen Private Tzaneen Thabazimbi Mediclinic Thabazimbi Mpumalanga Barberton Mediclinic Barberton Bronkhorstspruit Bronkhorstspruit Cosmos Emalahleni Ermelo Mediclinic Ermelo Kiaat Private Mbombela Lowveld Mbombela Nelspruit Mediclinic Mbombela Midmed Middelburg Piet Retief Piet Retief Secunda Mediclinic Secunda Highveld Mediclinic Trichardt North West Ingwe Access s Brits Mediclinic Brits Anncron Clinic Klerksdorp Victoria Private Mafikeng Potchefstroom Mediclinic Potchefstroom Ferncrest Rustenburg Peglerae Rustenburg Vryburg Private Vryburg Ingwe Access s Northern Cape Kathu Private Kathu Kimberley Mediclinic Kimberley Upington Mediclinic Upington Western Cape Bellville Medical Centre Bellville Louis Leipoldt Mediclinic Bellville Netcare Blaauwberg Blaauwberg Cape Gate Mediclinic Brackenfell Christiaan Barnard Memorial Cape Town Claremont Claremont Kingsbury Claremont Durbanville Mediclinic Durbanville Gatesville Medical Centre Gatesville Geneva Clinic George George Mediclinic George N1 City Goodwood Hermanus Mediclinic Hermanus Knysna Private Knysna Kuils River Private Kuils River UCT Private Academic Mowbray Milnerton Mediclinic Milnerton Mitchells Plain Medical Centre Mitchells Plain Bayview Mossel Bay Cape Town Mediclinic Oranjezicht Klein Karoo Mediclinic Oudtshoorn Paarl Mediclinic Paarl Panorama Mediclinic Panorama Vincent Pallotti Pinelands Plettenberg Bay Mediclinic Plettenberg Bay Constantiaberg Mediclinic Plumstead Sport Science Orthopaedic Surgical Day Centre Rondebosch Vergelegen Mediclinic Somerset West Stellenbosch Mediclinic Stellenbosch Strand Mediclinic Strand West Coast Private Vredenburg Worcester Mediclinic Worcester These hospital lists are subject to change. 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10 Exclusions Prescribed Minimum Benefits Notwithstanding the limitations and exclusions set out below, beneficiaries shall be entitled to the Prescribed Minimum Benefits. Benefits Excluded General exclusions mentioned in this paragraph are not affected by any specific exclusions. Unless otherwise decided by the Scheme (and with the express exception of medicine or treatment approved and authorised in terms of any health management programme contracted to the Scheme), expenses incurred in connection with any of the following will not be paid by the Scheme, but may be claimed from Savings: 1. All costs incurred during waiting periods and for conditions which existed at the date of application for membership of the Scheme but were not disclosed; 2. All costs that exceed the annual maximum allowed for the particular category as set out in Annexure B of the Scheme Rules, for the benefit to which the beneficiary is entitled in terms of the Scheme Rules; 3. Injuries or conditions sustained during willful participation in a riot, civil commotion, war, invasion, terrorist activity or rebellion; 4. Professional speed contests or professional speed trials (professional defined as where the beneficiary s main form of income is derived from partaking in these contests); 5. Costs incurred as a result of failure to carry out the instructions of a medical doctor or dentist; 6. Health care not registered with the recognised professional body constituted in terms of an Act of parliament; 7. Holidays for recuperative purposes, whether deemed medically necessary or not, including headache and stress relief clinics; 8. All costs for treatment if the efficacy and safety of such treatment cannot be proved; 9. All costs for operations, medicine, treatments and procedures for cosmetic purposes or for personal reasons and not directly caused by or related to illness, accident or disease. This includes the costs of treatment or surgery related to transsexual procedures; 10. Obesity; 11. Costs for attempted suicide that exceed the Prescribed Minimum Benefits limits; 12. Breast reduction and breast augmentation, gynaecomastia, otoplasty and blepharoplasty; 13. Medication not registered by the Medicine Control Council; 14. Costs for services rendered by any institution, nursing home or similar institution not registered in terms of any law (except a State facility/hospital); 15. Gum guards and gold used in dentures; 16. Frail care; 17. Travelling expenses, excluding benefits covered by Emergency rescue and International cover; 18. All costs, which in the opinion of the Medical Assessor are not medically necessary or appropriate to meet the health care needs of the patient; 19. Appointments which a beneficiary fails to keep; 20. Circumcision, unless clinically indicated, and any contraceptive measures or devices; 21. Reversal of Vasectomies or tubal ligation (sterilisation); 22. Injuries resulting from narcotism or alcohol abuse except for the Prescribed Minimum Benefits; 23. Infertility treatment that is included as Prescribed Minimum Benefits will be covered in State facilities subject to paragraph 4 of Annexure D of the Scheme Rules; 24. The cost of injury and any other related costs as a result of scuba diving to depths below 40 metres and cave diving

11 Momentum Health Council for Medical Schemes Member call centre Emergency evacuation Fraud hotline Customer Care Centre Canegate Road La Lucia Ridge PO Box 2338 Durban 4000 South Africa for queries for claims Version momentumhealth.mobi Registered in terms of the Medical Schemes Act 131 of momentumhealth.mobi