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book Glossary
Agreed rate The agreed rate is the negotiated tariff fee payable to any designated service provider, including those listed on the network. GRP The generic reference price – the Fund bases its medicine benefits on the cost of generic medicines instead of brand-name medicines. Momentum Health Momentum Health is contracted to the Scheme for all managed healthcare services and the management of the Scheme's provider network. Scheme rate The Scheme rate is the tariff set by the Fund for reimbursement of claims, in the absence of any other agreed or contracted tariff with any service provider. SEP The single exit price is the legislated price of medicine. UPFS The uniform patient fee schedule is the fee schedule applied by the public sector. PMB CDL Prescribed Minimum Benefits (PMB) Chronic Disease List (CDL): PMBs are benefits that medical schemes must offer in terms of the Medical Schemes Act, 131 of 1998.
Primary Option
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STATE FACILITY
Associated professional services, i.e. doctor, physiotherapist, occupational therapist, dietician, etc.
In patient
Subject to overall annual limit
Single member: R18 900
Member + 1: R29 500
Member + 2: R38 300
Member + 3: R39 500
Member + 4: R40 000Treatment at State facility only; uniforMember patient fee schedule (UPFS) rates applicable
Maternity
Patient must register with MomentuMember Health within the first 16 weeks of the pregnancy
Due to high annual indemnity insurance fees by gynaecologists, co-payments may applyTreatment at State facility only; UPFS rates applicable
Subject to overall annual limit
Single member: R18 900
Member + 1: R29 500
Member + 2: R38 300
Member + 3: R39 500
Member + 4: R40 000Treatment at State facility only; uniforMember patient fee schedule (UPFS) rates applicable. Subject to overall annual limit.
Gynaecologist
vaginal delivery (tariff code 2614)
caesarean delivery (tariff code 2615)Patient must register with MomentuMember Health within the first 16 weeks of the pregnancy
Subject to overall annual limit
Single member: R18 900
Member + 1: R29 500
Member + 2: R38 300
Member + 3: R39 500
Member + 4: R40 000Treatment at State facility only; uniforMember patient fee schedule (UPFS) rates applicable
Intensive care unit
Subject to overall annual limit
Single member: R18 900
Member + 1: R29 500
Member + 2: R38 300
Member + 3: R39 500
Member + 4: R40 000Treatment at State facility only; uniforMember patient fee schedule (UPFS) rates applicable
Radiology
Subject to overall annual limit
Single member: R18 900
Member + 1: R29 500
Member + 2: R38 300
Member + 3: R39 500
Member + 4: R40 000Treatment at State facility only; uniforMember patient fee schedule (UPFS) rates applicable
Pathology
Subject to overall annual limit
Single member: R18 900
Member + 1: R29 500
Member + 2: R38 300
Member + 3: R39 500
Member + 4: R40 000Treatment at State facility only; uniforMember patient fee schedule (UPFS) rates applicable
MRI and CT scans
Authorisation must be obtained prior to treatment
Subject to overall annual limit
Single member: R18 900
Member + 1: R29 500
Member + 2: R38 300
Member + 3: R39 500
Member + 4: R40 000Treatment at State facility only; uniforMember patient fee schedule (UPFS) rates applicable
Internal prostheses and joint replacements
Defined as appliances placed internally in the body during an operation, as well as the replacement of artificial eyes and limbs
Dental implants of any nature are not included in the definition of internal prostheses Subject to overall annual limit
Single member: R18 900
Member + 1: R29 500
Member + 2: R38 300
Member + 3: R39 500
Member + 4: R40 000Treatment at State facility only; uniforMember patient fee schedule (UPFS) rates applicable
Maxillofacial and oral surgery
Trauma cases only as a result of an emergency or accident
No benefit for selective admission for specialised or advanced dentistry
Subject to overall annual limit
Single member: R18 900
Member + 1: R29 500
Member + 2: R38 300
Member + 3: R39 500
Member + 4: R40 000Treatment at State facility only; uniforMember patient fee schedule (UPFS) rates applicable
To-take-out medicine
Medicine dispensed upon discharge froMember hospital
Subject to overall annual limit
Single member: R18 900
Member + 1: R29 500
Member + 2: R38 300
Member + 3: R39 500
Member + 4: R40 000Treatment at State facility only; uniforMember patient fee schedule (UPFS) rates applicable
Radiotherapy and chemotherapy (for instance cancer treatment)
Authorisation must be obtained prior to treatment
Subject to overall annual limit
Single member: R18 900
Member + 1: R29 500
Member + 2: R38 300
Member + 3: R39 500
Member + 4: R40 000Treatment at State facility only; uniforMember patient fee schedule (UPFS) rates applicable
Transplants
Authorisation must be obtained prior to treatment
Subject to overall annual limit
Single member: R18 900
Member + 1: R29 500
Member + 2: R38 300
Member + 3: R39 500
Member + 4: R40 000Treatment at State facility only; uniforMember patient fee schedule (UPFS) rates applicable
Cardiothoracic interventions and surgery (including angiograms)
Authorisation must be obtained prior to treatment
Subject to overall annual limit
Single member: R18 900
Member + 1: R29 500
Member + 2: R38 300
Member + 3: R39 500
Member + 4: R40 000Treatment at State facility only; uniforMember patient fee schedule (UPFS) rates applicable
Neurosurgery
Authorisation must be obtained prior to treatment
Subject to overall annual limit
Single member: R18 900
Member + 1: R29 500
Member + 2: R38 300
Member + 3: R39 500
Member + 4: R40 000Treatment at State facility only; uniforMember patient fee schedule (UPFS) rates applicable
Renal dialysis
Authorisation must be obtained prior to treatment
Subject to overall annual limit
Single member: R18 900
Member + 1: R29 500
Member + 2: R38 300
Member + 3: R39 500
Member + 4: R40 000Treatment at State facility only; uniforMember patient fee schedule (UPFS) rates applicable
Care in lieu of hospitalisation
Authorisation must be obtained prior to treatment
Rehabilitation or terminal care
No benefit for home nursing and frail care services Subject to overall annual limit
May include rehabilitation or terminal care
Single member: R18 900
Member + 1: R29 500
Member + 2: R38 300
Member + 3: R39 500
Member + 4: R40 000Treatment at State facility only; uniforMember patient fee schedule (UPFS) rates applicable
Specialised procedures, i.e. scopes
Authorisation must be obtained prior to treatment
Members will be liable for any costs in excess of the specified benefits Subject to overall annual limit
Single member: R18 900
Member + 1: R29 500
Member + 2: R38 300
Member + 3: R39 500
Member + 4: R40 000Treatment at State facility only; uniforMember patient fee schedule (UPFS) rates applicable
Circumcision
a) Performed out of hospital
Authorisation must be obtained prior to treatment
Subject to overall annual limit
Single member: R18 900
Member + 1: R29 500
Member + 2: R38 300
Member + 3: R39 500
Member + 4: R40 000Treatment at State facility only; uniforMember patient fee schedule (UPFS) rates applicable
b) Performed in hospital
Authorisation must be obtained prior to treatment
Subject to overall annual limit
Single member: R18 900
Member + 1: R29 500
Member + 2: R38 300
Member + 3: R39 500
Member + 4: R40 000Treatment at State facility only; uniforMember patient fee schedule (UPFS) rates applicable
Trauma units
Benefit limited to stabilisation of patient only and thereafter transferral to designated service provider
Subject to authorisation and case management Subject to overall annual limit
Single member: R18 900
Member + 1: R29 500
Member + 2: R38 300
Member + 3: R39 500
Member + 4: R40 000Treatment at State facility only; uniforMember patient fee schedule (UPFS) rates applicable
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HIV/AIDS
Hospital pre-authorisation is required
This benefit is subject to enrolment on the HIV/AIDS programme Subject to overall annual limit
Single member: R18 900
Member + 1: R29 500
Member + 2: R38 300
Member + 3: R39 500
Member + 4: R40 000Treatment at State facility only; uniforMember patient fee schedule (UPFS) rates applicable