marketing brochure 2011

Transcription

1 marketing brochure 2011

2 contents Why Momentum Health? 2 The Benefit Structure 3 Make the right choice 4 Options: 6 Ingwe Option 8 Access Option 10 Custom Option 12 Incentive Option 14 Extender Option 16 Summit Option Health Platform Benefit 18 Specialised Procedures 20 Referral Procedures on Incentive and Extender Options 21 Chronic Benefit 22 Exclusions 24 Contact details 24 Momentum Complementary Products: 26 HealthReturns 26 Multiply leads the Journey to Wellness 27 Health Saver 27 Mobi your health at your fingertips 28 Health Funder 28 Health Waiver This brochure is a marketing aid. On joining the Scheme, all Momentum Health members receive a detailed member brochure. Scheme Rules will always take precedence and are available on request.

3 Why Momentum Health? At Momentum Health, we offer unrivalled flexibility, so you can find healthcare cover that best meets your individual needs and pocket. Through innovative benefit design and strategic partnerships, we provide you with exceptional value of choice. Momentum Health s Value of Choice philosophy means you can: save up to 30% on your contribution - without sacrificing any benefits - through our choice of providers earn up to R3 600 in cash from Momentum s HealthReturns programme in only a few steps including going for a free Health Assessment and being active enjoy a variety of free preventative care benefits under the Health Platform, including an annual health assessment, pregnancy scans and more make provision for additional healthcare benefits, such as vitamins, through the Health Saver access emergency numbers, member details, claims statements and more through your cellphone join Momentum s wellness programme, Multiply, and receive great discounts from more than 30 providers, such as Virgin Active, NuMetro, Garmin and more Choice. It is the future. 2

4 The Benefit Structure Momentum Health s benefit structure comprises four components: Major Medical Benefit Chronic Benefit Day-to-day Benefit Health Platform Benefit Together, these four components offer you comprehensive cover for the full spectrum of medical expenses. Major Medical Benefit The Major Medical Benefit provides cover for hospitalisation and certain out-of-hospital procedures that can safely be performed in a doctor s room, registered day clinic or out-patient facility, provided treatment is clinically appropriate and has been pre-authorised Chronic Benefit (Out-of-hospital benefit) The Chronic Benefit covers certain life-threatening ailments that need ongoing intervention. Chronic cover is unlimited according to the Chronic Disease List (CDL), which forms part of the Prescribed Minimum Benefits (PMBs). Chronic benefits are subject to registration and approval Day-to-day Benefit (Out-of-hospital benefit) This benefit provides for day-to-day medical expenses incurred out-of-hospital. Members have the choice of supplementing their day-today cover through the Health Saver Health Platform Benefit The Health Platform Benefit is available to all Momentum Health members and is paid by the Scheme (subject to pre-notification). Thus it does not deplete members day-to-day benefit. This unique benefit 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 emergency cover 3

5 Make the right 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 assess your needs, and make the right choice. Step 1: Choose your level of cover Major Medical Benefit Chronic Benefit Ingwe Option Access Option Custom Option Incentive Option Extender Option Summit Option Specialists covered up to 100% of MHR Hospital accounts covered in full at negotiated rate Limited to R per family per year for 26 conditions Subject to an entry-level formulary Specialists covered up to 100% of MHR Hospital accounts covered in full at negotiated rate for 26 conditions Subject to an entry-level formulary Associated specialists covered in full Other specialists covered up to 100% of MHR Hospital accounts covered in full at negotiated rate R850 co-payment applies Associated specialists covered in full Other specialists covered up to 200% of MHR Hospital accounts covered in full at negotiated rate for 26 conditions for 26 conditions - additional 6 conditions limited to R6 300 per family Associated specialists covered in full Other specialists covered up to 200% of MHR Hospital accounts covered in full at negotiated rate for 26 conditions - additional 36 conditions limited to R6 300 per family Associated specialists covered in full Other specialists covered up to 300% of MHR Hospital accounts covered in full at negotiated rate for 26 conditions - additional 36 conditions accumulate to the overall day-to-day limit of R per beneficiary. This is a combined limit incorporating both day-to-day cover and cover for the 36 additional conditions. Day-to-day Benefit Primary care Secondary care (Specialist visits) Primary care Secondary care (Specialist visits) Subject to Health Saver, if applicable Savings 10% of total contribution Savings 25% of total contribution plus Extended Cover Paid from risk benefit, subject to overall day-to-day limit of R per beneficiary. This is a combined limit incorporating both day-to-day cover and cover for the 36 additional conditions. Health Saver Voluntary amount to suit your needs Voluntary amount to suit your needs Voluntary amount to suit your needs Voluntary amount to suit your needs Voluntary amount to suit your needs Voluntary amount to suit your needs Step 2: Choose your provider Use the following guide to choose your provider - your choice of provider determines your monthly contribution. Ingwe Option Access Option Custom Option Incentive Option Extender Option Summit Option In-hospital State or Ingwe Network hospitals Access Network hospitals Any or Associated hospitals Any or Associated hospitals Any or Associated hospitals Any hospital Out-of-hospital CareCross or Prime Cure CareCross, Medicross or Prime Cure Any, Associated or State Any, Associated or State Any, Associated or State Freedom-of-choice Certain formularies apply to the Chronic Benefit Entry-level formulary Entry-level formulary Any: Reference Price List Associated: Entry-level formulary State: Entry-level formulary Any: Reference Price List Associated: Entry-level formulary State: Entry-level formulary Any: Reference Price List Associated: Entry-level formulary State: Entry-level formulary No formularies apply Step 3: Choose from a wide range of complementary Momentum products Choose from Momentum s range of complementary products and rewards to enhance your Momentum Health option. You will find more information on Health Saver, Multiply, HealthReturns, Health Waiver, Health Funder and our Mobi offering on page 25 of this brochure. Glossary of providers In-hospital providers (Major Medical Benefit) Out-of-hospital providers (Chronic and Day-to-day benefits) Ingwe Network hospitals Selected Life Healthcare hospitals Any Any GP and any pharmacy Access Network hospitals Selected Netcare hospitals Associated Any hospital Any private hospital State Associated hospitals Selected Life Healthcare and Medi-Clinic hospitals Selected preferred GPs and Courier pharmacies (chronic medication) Any GP for Day-to-day benefits and State facilities for Chronic benefits Example: Step 1: Choose your level of cover If you require extensive cover in-hospital and do not require comprehensive day-to-day cover, choose the Incentive Option. Step 2: Choose your providers If you are willing to use a network of private hospitals and a network of GPs and pharmacies, choose Associated providers. Thus, your option will be the Incentive Option, with Associated hospitals and Associated out-of-hospital providers. Step 3: Choose from a wide range of complementary Momentum products See page 25 for more. Associated specialists Selected preferred specialists 4 5

6 Ingwe Option The Ingwe Option provides affordable access to entry-level cover at preferred providers. Hospitalisation is available from one of two providers, Ingwe Network (list of private hospitals) or State hospitals, subject to a limit of R per family per year. Chronic and primary care day-to-day benefits are provided at CareCross or Prime Cure. How much will you pay per month? Monthly family income In-hospital provider Out-of-hospital provider R3 750 State CareCross R318 R636 R491 R809 R982 R1 155 R3 750 State Prime Cure R383 R766 R567 R950 R1 134 R1 318 R3 751 R6 000 R6 001 R8 000 State State CareCross or Prime Cure CareCross or Prime Cure R383 R766 R567 R950 R1 134 R1 318 R440 R880 R631 R1 071 R1 262 R1 453 > R8 000 State CareCross or Prime Cure R741 R1 450 R965 R1 674 R1 898 R2 122 R3 750 Ingwe Network CareCross R427 R854 R631 R1 058 R1 262 R1 466 R3 750 Ingwe Network Prime Cure R592 R1 184 R809 R1 401 R1 618 R1 835 R3 751 R6 000 R6 001 R8 000 Ingwe Network Ingwe Network > R8 000 Ingwe Network CareCross or Prime Cure CareCross or Prime Cure CareCross or Prime Cure R592 R1 184 R809 R1 401 R1 618 R1 835 R758 R1 478 R986 R1 706 R1 934 R2 162 R1 002 R1 954 R1 303 R2 255 R2 556 R2 857 Individual contribution table: Monthly family income In-hospital provider Out-of-hospital provider P A C R3 750 State CareCross R318 R318 R173 R3 750 State Prime Cure R383 R383 R184 R3 751 R6 000 State CareCross or Prime Cure R383 R383 R184 R6 001 R8 000 State CareCross or Prime Cure > R8 000 State CareCross or Prime Cure R440 R440 R191 R741 R709 R224 R3 750 Ingwe Network CareCross R427 R427 R204 R3 750 Ingwe Network Prime Cure R592 R592 R217 R3 751 R6 000 Ingwe Network CareCross or Prime Cure R592 R592 R217 R6 001 R8 000 Ingwe Network CareCross or Prime Cure > R8 000 Ingwe Network CareCross or Prime Cure P = Principal A = Adult C = Child R758 R720 R228 R1 002 R952 R301 6

7 Major Medical Benefit Benefit Co-payment High and intensive care Dialysis and oncology Organ transplants In-hospital dentistry Maternity confinements (limit for hospital account only) Elective caesareans covered up to the uncomplicated delivery limit Neonatal intensive care Medical and surgical appliances in-hospital (support stockings, knee and back braces etc.) Prosthesis internal (incl. knee and hip replacements, permanent pacemakers etc.) Prosthesis external (artificial arms or legs etc.) Mental health - incl. psychiatry and psychology - drug and alcohol rehabilitation Take-home medicines Rehabilitation and step-down facilities Private nursing and Hospice Immune deficiency related to HIV Anti-retroviral treatment In-hospital Aids cases Chronic Benefit Cover Day-to-day Benefit Savings Acupuncture, Homeopathy, Naturopathy, Herbology, Audiology, Occupational and Speech therapy, Chiropractors, Dieticians, Biokinetics, Orthoptists, Osteopathy, Audiometry, Chiropody and Podiatry Mental health (incl. psychiatry and psychology) Dentistry basic Dentistry specialised External medical and surgical appliances (incl. hearing aids, glucometers, blood pressure monitors, wheelchairs etc.) General practitioners Out-of-network GP, casualty or after-hours visits Specialists Physiotherapy Optical and optometry (excl. contact lenses and refractive eye surgery) Pathology basic Radiology basic Prescribed medication Over-the-counter medication MRI and CT scans Specialists covered up to 100% of MHR Hospital accounts covered in full at negotiated rate Limited to R per family per year Ingwe Network or State hospitals None Subject to authorisation, management programmes, clinical protocols and Scheme rules. Sub-limits apply per year, unless stated otherwise 10 days per admission Limited to PMBs at State facilities Limited to PMBs at State facilities, maxillo-facial trauma covered at State facilities R for uncomplicated delivery R for complicated delivery Covered in private Ingwe Network hospitals R per confinement R3 350 per family Limited to PMBs at State facilities, 21-day sub-limit applies to drug and alcohol rehabilitation 7 days supply R8 000 per beneficiary At preferred provider R per family R per family CareCross or Prime Cure 26 conditions, according to CDL in PMBs Benefits are only available at the chosen preferred provider and are subject to an entrylevel formulary CareCross or Prime Cure None Benefits are only available at the chosen preferred provider and are subject to the preferred provider s protocol, formulary and office hours. Sub-limits apply per year, unless stated otherwise. applies. applies 1 visit per beneficiary per year, subject to authorisation Maximum of two visits per family per year Limited to R730 per event, 20% co-payment applies 1 visit per family per year, 10% co-payment applies. Subject to referral by preferred provider and pre-authorisation Included in the specialist limit One eye test and one pair of clear standard or bi-focal lenses with standard frame as per formulary per beneficiary every two years. Subject to qualifying criteria. applies. applies Subject to an entry-level formulary This table represents a summary of the benefits for 2011 MHR is the Momentum Health Rate, which is the rate that Momentum Health sets for the reimbursement of claims CDL: Chronic Disease List PMB: Prescribed Minimum Benefits Chronic and Day-to-day Benefits are only available from the chosen preferred provider If members choose Ingwe Network hospitals as their preferred provider for the Major Medical Benefit and do not use this provider, they will have a co-payment of 30%. If members choose State hospitals as their preferred provider for the Major Medical Benefit and do not use this provider, a co-payment will apply. This co-payment will be the difference in the cost between State facility charges and the amount charged by the provider they use 7

8 Access Option The Access Option is designed for members who require unlimited private hospitalisation at a group of network hospitals. Chronic and primary care day-to-day benefits are available from preferred providers, CareCross, Medicross or Prime Cure. How much will you pay per month? In-hospital provider Access Network Out-of-hospital provider CareCross, Medicross or Prime Cure R1 072 R2 091 R1 393 R2 412 R2 733 R3 054 Individual contribution table: In-hospital provider Out-of-hospital provider P A C Access Network P = Principal A = Adult C = Child CareCross, Medicross or Prime Cure R1 072 R1 019 R321 8

9 Major Medical Benefit Benefit Co-payment High and intensive care Dialysis and oncology Organ transplants In-hospital dentistry Maternity confinements Neonatal intensive care Medical and surgical appliances in-hospital (support stockings, knee and back braces etc.) Prosthesis internal (incl. knee and hip replacements, permanent pacemakers, etc.) Prosthesis external (artificial arms or legs etc.) Mental health - incl. psychiatry and psychology - drug and alcohol rehabilitation Take-home medicines Rehabilitation, private nursing, Hospice and step-down facilities Immune deficiency related to HIV Anti-retroviral treatment In-hospital Aids cases Chronic Benefit Cover Day-to-day Benefit Savings Acupuncture, Homeopathy, Naturopathy, Herbology, Audiology, Occupational and Speech therapy, Chiropractors, Dieticians, Biokinetics, Orthoptists, Osteopathy, Audiometry, Chiropody, Physiotherapy and Podiatry Mental health (incl. psychiatry and psychology) Dentistry basic Dentistry specialised External medical and surgical appliances (incl. hearing aids, glucometers, blood pressure monitors, wheelchairs etc.) General practitioners Out-of-network GP, casualty or after-hours visits Specialists Optical and optometry (excl. contact lenses and refractive eye surgery) Pathology basic Radiology basic Prescribed medication Over-the-counter medication MRI and CT scans Specialists covered up to 100% of MHR Hospital accounts covered in full at negotiated rate Access Network hospitals None Subject to authorisation, management programmes, clinical protocols and Scheme rules. Sub-limits apply per year, unless stated otherwise 12 days per admission Limited to PMBs at State facilities Limited to PMBs at State facilities, maxillo-facial trauma covered at State facilities R4 050 per family Intraocular lenses: R3 500 per beneficiary per event, maximum 2 events per year Other internal prostheses: R per beneficiary per event, maximum 2 events per year Annual limit for mental health of R per beneficiary, 21-day sub-limit applies to drug and alcohol rehabilitation, subject to treatment at preferred provider 7 days supply R per family At preferred provider R per family R per family CareCross, Medicross or Prime Cure 26 conditions, according to CDL in PMBs Benefits are only available at the chosen preferred provider and are subject to an entrylevel formulary CareCross, Medicross or Prime Cure None Benefits are only available at the chosen preferred provider and are subject to the preferred provider s protocol, formulary and office-hours. Sub-limits apply per year unless stated otherwise. applies 10 visits per beneficiary, thereafter a 10% co-payment applies 1 visit per beneficiary per year, subject to authorisation Maximum of two visits per family per year Limited to R730 per event, 20% co-payment applies 3 visits per beneficiary, max. 5 visits per family, subject to referral by preferred provider One eye test and one pair of clear standard or bi-focal lenses with standard frame as per formulary per beneficiary every two years. Subject to qualifying criteria. applies. applies Subject to an entry-level formulary. If the item is not on the formulary, a co-payment applies This table represents a summary of the benefits for 2011 MHR is the Momentum Health Rate, which is the rate that Momentum Health sets for the reimbursement of claims CDL: Chronic Disease List PMB: Prescribed Minimum Benefits If members do not use Access Network hospitals, they will have a co-payment of 30% 9

10 Custom Option The Custom Option is designed for members who require unlimited private hospitalisation. There is a co-payment of R850 per authorisation on the Major Medical Benefit, except in the case of motor vehicle accidents and maternity confinements. Members have the flexibility to choose their providers this choice determines the contribution payable. Members can add the Health Saver to fund their day-to-day healthcare expenses. How much will you pay per month? In-hospital provider Out-of-hospital provider Any Any R1 132 R2 041 R1 537 R2 446 R2 851 R3 256 Any Associated R1 063 R1 892 R1 449 R2 278 R2 664 R3 050 Any State R1 010 R1 773 R1 380 R2 143 R2 513 R2 883 Associated Any R970 R1 735 R1 313 R2 078 R2 421 R2 764 Associated Associated R885 R1 570 R1 198 R1 883 R2 196 R2 509 Associated State R786 R1 381 R1 064 R1 659 R1 937 R2 215 Individual contribution table: Step 1: Choose your in-hospital provider Any or Associated Step 2: Choose your out-of-hospital provider If you choose Any in-hospital provider, select one of the three out-of-hospital providers below: If you choose Associated in-hospital provider, select one of the three out-of-hospital providers below: Any P A C Any P A C Total contribution R1 132 R909 R405 Total contribution R970 R765 R343 Associated P A C Associated P A C Total contribution R1 063 R829 R386 Total contribution R885 R685 R313 State P A C State P A C Total contribution R1 010 R763 R370 Total contribution R786 R595 R278 P = Principal A = Adult C = Child (Maximum of 3 children charged for) 10

11 Major Medical Benefit Benefit Co-payment High and intensive care Casualty or after-hour visits Dialysis Oncology* Organ transplants (recipient) Organ transplants (donor) Only covered when recipient is a member of the Scheme In-hospital dentistry: - maxillo-facial surgery and impacted wisdom teeth - general anaesthesia for children under 7 Maternity confinements Neonatal intensive care MRI and CT scans (in- and out-of-hospital) Medical and surgical appliances in-hospital (support stockings, knee and back braces etc.) Prosthesis internal (incl. knee and hip replacements, permanent pacemakers etc.) Prosthesis - external (artificial arms or legs etc.) Mental health - incl. psychiatry and psychology - drug and alcohol rehabilitation Take-home medicines Rehabilitation, private nursing, Hospice and step-down facilities Immune deficiency related to HIV Anti-retroviral treatment In-hospital Aids cases Chronic Benefit Cover Day-to-day Benefit Savings Acupuncture, Homeopathy, Naturopathy, Herbology, Audiology, Occupational and Speech therapy, Chiropractors, Dieticians, Biokinetics, Orthoptists, Osteopathy, Audiometry, Chiropody, Physiotherapy and Podiatry Mental health (incl. psychiatry and psychology) Dentistry basic Dentistry specialised External medical and surgical appliances (incl. hearing aids, glucometers, blood pressure monitors, wheelchairs etc.) General practitioners Specialists Optical and optometry (incl. contact lenses and refractive eye surgery) Pathology Radiology Prescribed medication Over-the-counter medication Associated specialists covered in full Other specialists covered up to 100% of MHR Hospital accounts covered in full at negotiated rate Any or Associated hospitals R850 per authorisation, except for motor vehicle accidents, maternity confinements and emergency treatment Subject to authorisation, management programmes, clinical protocols and Scheme rules. Sub-limits apply per year, unless stated otherwise Subject to Health Saver, if available R per beneficiary per year, thereafter a 20% co-payment applies R cadaver costs R live donor costs (incl. transportation) Hospital and anaesthetist account paid from Major Medical Benefit, subject to R850 co-payment per authorisation. Dental, dental specialist and maxillo-facial surgeon accounts paid from Health Saver, if available, subject to R1 600 co-payment per scan R4 050 per family Intraocular lenses: R3 500 per beneficiary per event, maximum 2 events per year Other internal prostheses: R per beneficiary per event, maximum 2 events per year R per family Annual limit for mental health of R per beneficiary, 21-day sub-limit applies to drug and alcohol rehabilitation, subject to treatment at preferred provider 7 days supply R per family At preferred provider R per family Any, Associated or State 26 conditions, according to CDL in PMBs Benefits are subject to registration and approval Any None Benefits are subject to Health Saver, if available Subject to Health Saver, if available Subject to Health Saver, if available Subject to Health Saver, if available Subject to Health Saver, if available Subject to Health Saver, if available Subject to Health Saver, if available Subject to Health Saver, if available Subject to Health Saver, if available Subject to Health Saver, if available Subject to Health Saver, if available (MRI and CT scans covered from Major Medical Benefit) Subject to Health Saver, if available Subject to Health Saver, if available This table represents a summary of the benefits for 2011 MHR is the Momentum Health Rate, which is the rate that Momentum Health sets for the reimbursement of claims CDL: Chronic Disease List PMB: Prescribed Minimum Benefits If members choose Associated hospitals as their preferred provider for the Major Medical Benefit and do not use this provider, they will have a co-payment of 30%. *Newly diagnosed beneficiaries who selected State as their out-of-hospital provider must obtain their treatment from an authorised oncologist. 11

12 Incentive Option The Incentive Option is designed for members who require unlimited private hospitalisation and average day-to-day cover. Members have the flexibility to choose their in- and out-of-hospital providers this choice determines the contribution payable. This option provides Savings of 10% of the contribution for day-to-day healthcare expenses, which can be supplemented through the Health Saver. How much will you pay per month? In-hospital provider Out-of-hospital provider Any Any R1 477 R2 676 R2 051 R3 250 R3 824 R4 398 Any Associated R1 392 R2 509 R1 939 R3 056 R3 603 R4 150 Any State R1 272 R2 274 R1 774 R2 776 R3 278 R3 780 Associated Any R1 377 R2 485 R1 891 R2 999 R3 513 R4 027 Associated Associated R1 257 R2 257 R1 735 R2 735 R3 213 R3 691 Associated State R1 090 R1 944 R1 513 R2 367 R2 790 R3 213 Individual contribution table: Step 1: Choose your in-hospital provider Any or Associated Step 2: Choose your out-of-hospital provider If you choose Any in-hospital provider, select one of the three out-of-hospital providers below: If you choose Associated in-hospital provider, select one of the three out-of-hospital providers below: Any P A C Any P A C Total contribution R1 477 R1 199 R574 Total contribution R1 377 R1 108 R514 Risk contribution R1 329 R1 079 R517 Risk contribution R1 239 R997 R463 Savings 10% R148 R120 R57 Savings 10% R138 R111 R51 Annual Savings R1 776 R1 440 R684 Annual Savings R1 656 R1 332 R612 Associated P A C Associated P A C Total contribution R1 392 R1 117 R547 Total contribution R1 257 R R478 Risk contribution R1 253 R1 005 R492 Risk contribution R1 131 R 900 R430 Savings 10% R139 R112 R55 Savings 10% R126 R100 R48 Annual Savings R1 668 R1 344 R660 Annual Savings R1 512 R1 200 R576 State P A C State P A C Total contribution R1 272 R1 002 R 502 Total contribution R1 090 R854 R423 Risk contribution R1 145 R902 R452 Risk contribution R981 R769 R381 Savings 10% R127 R100 R50 Savings 10% R109 R85 R42 Annual Savings R1 524 R1 200 R600 Annual Savings R1 308 R1 020 R504 P = Principal A = Adult C = Child (Maximum of 3 children charged for) 12

13 Major Medical Benefit Benefit Associated specialists covered in full Other specialists covered up to 200% of MHR Hospital accounts covered in full at negotiated rate Any or Associated hospitals Co-payment Co-payments apply per specialist for 17 referral procedures - see page 21 Subject to authorisation, management programmes, clinical protocols and Scheme rules. Sub-limits apply per year, unless stated otherwise High and intensive care Casualty or after-hour visits Subject to Savings Dialysis Oncology* R per beneficiary per year, thereafter a 20% co-payment applies Organ transplants (recipient) Organ transplants (donor) Only covered when recipient is a member of the Scheme In-hospital dentistry: - maxillo-facial surgery and impacted wisdom teeth - general anaesthesia for children under 7 Maternity confinements Neonatal intensive care MRI and CT scans (in- and out-of-hospital) Medical and surgical appliances in-hospital (support stockings, knee and back braces etc.) Prosthesis internal (incl. knee and hip replacements, permanent pacemakers etc.) Prosthesis - external (artificial arms or legs etc.) Mental health - incl. psychiatry and psychology - drug and alcohol rehabilitation Take-home medicines Rehabilitation, private nursing, Hospice and step-down facilities Immune deficiency related to HIV Anti-retroviral treatment In-hospital Aids cases Chronic Benefit Cover Day-to-day Benefit Savings Acupuncture, Homeopathy, Naturopathy, Herbology, Audiology, Occupational and Speech therapy, Chiropractors, Dieticians, Biokinetics, Orthoptists, Osteopathy, Audiometry, Chiropody, Physiotherapy and Podiatry Mental health (incl. psychology and psychiatry) Dentistry basic Dentistry specialised External medical and surgical appliances (incl. hearing aids, glucometers, blood pressure monitors, wheelchairs etc.) General practitioners Specialists Optical and optometry (incl. contact lenses and refractive eye surgery) Pathology Radiology Prescribed medication Over-the-counter medication R cadaver costs R live donor costs (incl. transportation) Hospital and anaesthetist account paid from Major Medical Benefit, subject to R1 200 co-payment per authorisation. Dental, dental specialist and maxillo-facial surgeon accounts paid from Savings, if available, subject to R1 600 co-payment per scan R4 050 per family Cochlear implants: R per beneficiary, maximum 1 event per year Intraocular lenses: R4 500 per beneficiary per event, maximum 2 events per year Other internal prostheses: R per beneficiary per event, maximum 2 events per year R per family Annual limit for mental health of R per beneficiary, 21-day sub-limit applies to drug and alcohol rehabilitation, subject to treatment at preferred provider 7 days supply R per family At preferred provider R per family Any, Associated or State Cover for 32 conditions: 26 conditions, according to CDL in PMBs - unlimited; 6 additional conditions - limited to R6 300 per family per year Benefits subject to registration and approval Any Fixed at 10% of total contribution Benefits are subject to Savings, claims are paid at cost with no sub-limits Subject to Savings Subject to Savings Subject to Savings Subject to Savings Subject to Savings Subject to Savings Subject to Savings Subject to Savings Subject to Savings Subject to Savings (MRI and CT scans covered from Major Medical Benefit) Subject to Savings Subject to Savings This table represents a summary of the benefits for 2011 MHR is the Momentum Health Rate, which is the rate that Momentum Health sets for the reimbursement of claims CDL: Chronic Disease List PMB: Prescribed Minimum Benefits If members choose Associated hospitals as their preferred provider for Major Medical Benefit, and do not use this provider, they will have a co-payment of 30% *Newly diagnosed beneficiaries who selected State as their out-of-hospital provider must obtain their treatment from an authorised oncologist. 13

14 Extender Option The Extender Option is designed for members who require unlimited private hospitalisation, as well as extensive chronic cover and day-to-day benefits. Members have the flexibility to choose their in- and out-of-hospital providers this choice determines the contribution payable. How much will you pay per month? In-hospital provider Out-of-hospital provider Any Any R2 739 R4 923 R3 598 R5 782 R6 641 R7 500 Any Associated R2 505 R4 505 R3 290 R5 290 R6 075 R6 860 Any State R2 341 R4 209 R3 074 R4 942 R5 675 R6 408 Associated Any R2 451 R4 407 R3 219 R5 175 R5 943 R6 711 Associated Associated R2 259 R4 060 R2 968 R4 769 R5 478 R6 187 Associated State R2 081 R3 614 R2 734 R4 267 R4 920 R5 573 Individual contribution table: Step 1: Choose your in-hospital provider Any or Associated Step 2: Choose your out-of-hospital provider If you choose Any in-hospital provider, select one of the three out-of-hospital providers below: If you choose Associated in-hospital provider, select one of the three out-of-hospital providers below: Any P A C Any P A C Total contribution R2 739 R2 184 R859 Total contribution R2 451 R1 956 R768 Risk contribution R2 054 R1 638 R644 Risk contribution R1 838 R1 467 R576 Savings 25% R685 R546 R215 Savings 25% R613 R489 R192 Annual Savings R8 220 R6 552 R2 580 Annual Savings R7 356 R5 868 R2 304 Threshold R9 600 R8 400 R2 700 Threshold R9 600 R8 400 R2 700 Associated P A C Associated P A C Total contribution R2 505 R2 000 R785 Total contribution R2 259 R1 801 R709 Risk contribution R1 879 R1 500 R589 Risk contribution R1 694 R1 351 R532 Savings 25% R626 R500 R196 Savings 25% R565 R450 R177 Annual Savings R7 512 R6 000 R2 352 Annual Savings R6 780 R5 400 R2 124 Threshold R9 600 R8 400 R2 700 Threshold R9 600 R8 400 R2 700 State P A C State P A C Total contribution R2 341 R R733 Total contribution R2 081 R1 533 R653 Risk contribution R1 756 R1 401 R550 Risk contribution R1 561 R1 150 R490 Savings 25% R585 R467 R183 Savings 25% R520 R383 R163 Annual Savings R7 020 R5 604 R2 196 Annual Savings R6 240 R4 596 R1 956 Threshold R9 600 R8 400 R2 700 Threshold R9 600 R8 400 R2 700 P = Principal A = Adult C = Child (Maximum of 3 children charged for) 14

15 Major Medical Benefit Benefit Associated specialists covered in full Other specialists covered up to 200% of MHR Hospital accounts covered in full at negotiated rate Any or Associated hospitals Co-payment Co-payments apply per specialist for 17 referral procedures - see page 21 Subject to authorisation, management programmes, clinical protocols and Scheme rules. Sub-limits apply per year, unless stated otherwise High and intensive care Casualty or after-hour visits Subject to Day-to-day Benefit Dialysis Oncology* R per beneficiary per year, thereafter a 20% co-payment applies Organ transplants (recipient) Organ transplants (donor) Only covered when recipient is a member of the Scheme In-hospital dentistry: - maxillo-facial surgery and impacted wisdom teeth - general anaesthesia for children under 7 Maternity confinements Neonatal intensive care MRI and CT scans (in- and out-of-hospital) Medical and surgical appliances in-hospital (support stockings, knee and back braces etc.) Prosthesis internal (incl. knee and hip replacements, permanent pacemakers etc.) Prosthesis - external (artificial arms or legs etc.) Mental health - incl. psychiatry and psychology - drug and alcohol rehabilitation Take-home medicines Rehabilitation, private nursing, Hospice and step-down facilities Immune deficiency related to HIV Anti-retroviral treatment In-hospital Aids cases Chronic Benefit Cover Day-to-day Benefit R cadaver costs R live donor costs (incl. transportation) Hospital and anaesthetist account paid from Major Medical Benefit, subject to R1 200 co-payment per authorisation. Dental, dental specialist and maxillo-facial surgeon accounts paid from Day-to-day Benefit and accumulate towards limit, subject to R1 600 co-payment per scan R4 050 per family Cochlear implants: R per beneficiary, maximum 1 event per year Intraocular lenses: R4 500 per beneficiary per event, maximum 2 events per year Other internal prostheses: R per beneficiary per event, maximum 2 events per year R per family Annual limit for mental health of R per beneficiary, 21-day sub-limit applies to drug and alcohol rehabilitation, subject to treatment at preferred provider 7 days supply R per family At preferred provider R per family Any, Associated or State Cover for 62 conditions: 26 conditions, according to CDL in PMBs - unlimited 36 additional conditions - limited to R6 300 per family per year Benefits subject to registration and approval Any, Associated or State Savings Annual Threshold levels: Member: R9 600 Per adult dependant: R8 400 Per child: R2 700 (max. 3 children) Acupuncture, Homeopathy, Naturopathy, Herbology, Audiology, Occupational and Speech therapy, Chiropractors, Dieticians, Biokinetics, Orthoptists, Osteopathy, Audiometry, Chiropody, Physiotherapy and Podiatry Mental health (incl. psychology and psychiatry) Dentistry basic Dentistry specialised External medical and surgical appliances (incl. hearing aids, glucometers, blood pressure monitors, wheelchairs etc.) General practitioners Specialists Optical and optometry (incl. contact lenses and refractive eye surgery) Pathology Radiology Prescribed medication Over-the-counter medication (incl. prescribed vitamins) Fixed at 25% of total contribution Benefits are first paid from Savings. The member is liable for payment of certain claims (self-funding gap) before Extended Cover is activated. Claims accumulate to Threshold and are paid from Extended Cover at 100% of MHR. Annual sub-limits apply before and after Threshold R per family R8 300 per beneficiary, R per family. Both in-and out-of-hospital dental specialist accounts accumulate towards the limit R per family R4 700 sub-limit for hearing aids Depending on the out-of-hospital provider selected Any or State provider: Associated providers: 100% of MHR for Associated GPs 70% of MHR for non-associated GPs Overall limit of R2 600 per beneficiary Frame sub-limit of R1 400 (MRI and CT scans covered from Major Medical Benefit) R per beneficiary, R per family R per beneficiary, R per family This table represents a summary of the benefits for 2011 MHR is the Momentum Health Rate, which is the rate that Momentum Health sets for the reimbursement of claims CDL: Chronic Disease List PMB: Prescribed Minimum Benefits If members choose Associated hospitals as their preferred provider for Major Medical Benefit and do not use this provider, they will have a co-payment of 30% *Newly diagnosed beneficiaries who selected State as their out-of-hospital provider must obtain their treatment from an authorised oncologist. 15

16 Summit Option The Summit Option is designed for members who require unlimited private hospitalisation, as well as extensive chronic cover and dayto-day benefits. Members have the Freedom-of-choice to use any provider. How much will you pay per month? In-hospital provider Out-of-hospital provider Any Freedom-of-choice R3 934 R7 081 R4 838 R7 985 R8 889 R9 793 Individual contribution table: In-hospital provider Out-of-hospital provider P A C Any Freedom-of-choice R3 934 R3 147 R904 P = Principal A = Adult C = Child (Maximum of 3 children charged for) 16

17 Major Medical Benefit Benefit Co-payment High and intensive care Casualty or after-hour visits Dialysis and oncology Organ transplants (recipient) Organ transplants (donor) Only covered when recipient is a member of the Scheme In-hospital dentistry: - maxillo-facial surgery and impacted wisdom teeth - general anaesthesia for children under 7 Maternity confinements Neonatal intensive care MRI and CT scans (in- and out-of-hospital) Medical and surgical appliances in-hospital (support stockings, knee and back braces etc.) Prosthesis internal (incl. knee and hip replacements, permanent pacemakers etc.) Prosthesis external (artificial arms or legs etc.) Mental health - incl. psychiatry and psychology - drug and alcohol rehabilitation Take-home medicines Rehabilitation, private nursing, Hospice and step-down facilities Immune deficiency related to HIV Anti-retroviral treatment In-hospital Aids cases Chronic Benefit Cover Day-to-day Benefit Savings Acupuncture, Homeopathy, Naturopathy, Herbology, Audiology, Occupational and Speech therapy, Chiropractors, Dieticians, Biokinetics, Orthoptists, Osteopathy, Audiometry, Chiropody, Physiotherapy and Podiatry Mental health (incl. psychiatry and psychology) Dentistry basic Dentistry specialised External medical and surgical appliances (incl. hearing aids, glucometers, blood pressure monitors, wheelchairs etc.) General practitioners Specialists Optical and optometry (incl. contact lenses and refractive eye surgery) Pathology Radiology Prescribed medication Over-the-counter medication (including prescribed vitamins) Associated specialists covered in full Other specialists covered up to 300% of MHR Hospital accounts covered in full at negotiated rate Any hospital No Subject to authorisation, management programmes, clinical protocols and Scheme rules. Sub-limits apply per year, unless stated otherwise Subject to Day-to-day Benefit R cadaver costs R live donor costs (incl. transportation) Hospital and anaesthetist accounts paid from Major Medical Benefit. Dental, dental specialist and maxillo-facial surgeon accounts paid from Day-to-day Benefit and accumulate towards overall day-to-day limit of R per beneficiary, subject to R1 600 co-payment per scan R4 050 per family Cochlear implants: R per beneficiary, maximum 1 event per year Intraocular lenses: R4 500 per beneficiary per event, maximum 2 events per year Other internal prostheses: R per beneficiary per event, maximum 2 events per year R per family Annual limit for mental health of R per beneficiary, 21-day sub-limit applies to drug and alcohol rehabilitation, subject to treatment at preferred provider 7 days supply R per family At preferred provider R per family Freedom-of-choice Cover for 62 conditions 26 conditions according to CDL in PMBs - unlimited 36 additional conditions - accumulate to overall day-to-day limit of R per beneficiary. This is a combined limit incorporating both day-to-day cover and cover for the 36 additional conditions. Benefits subject to registration and approval Freedom-of-choice Not applicable Benefits are paid at 100% of MHR by the Scheme, subject to certain sub-limits and an overall day-to-day limit of R per beneficiary. Limits apply per year unless stated otherwise R4 700 per family. Subject to overall annual day-to-day limit of R per beneficiary R per family. Subject to overall annual day-to-day limit of R per beneficiary Subject to overall day-to-day limit of R per beneficiary R9 600 per beneficiary, R per family. Both in-and out-of-hospital dental specialist accounts accumulate towards the limit. Subject to overall annual day-to-day limit of R per beneficiary R per family. Subject to overall annual day-to-day limit of R per beneficiary R sub-limit for hearing aids. Subject to overall annual day-to-day limit of R per beneficiary Subject to overall day-to-day limit of R per beneficiary Subject to overall day-to-day limit of R per beneficiary Overall limit of R2 900 per beneficiary. Subject to annual day-to-day limit of R per beneficiary Frame sub-limit of R Subject to overall annual day-to-day limit of R per beneficiary Subject to overall day-to-day limit of R per beneficiary Subject to overall day-to-day limit of R per beneficiary (MRI and CT scans covered from Major Medical Benefit) R per beneficiary, R per family. Subject to overall annual day-to-day limit of R per beneficiary This table represents a summary of the benefits for 2011 MHR is the Momentum Health Rate, which is the rate that Momentum Health sets for the reimbursement of claims CDL: Chronic Disease List PMB: Prescribed Minimum Benefits 17

18 Health Platform Benefit Health Platform benefits are paid by the Scheme up to a maximum Rand amount per benefit, and are subject to pre-notification. The maximum Rand amount is determined according to specific tariff codes. On Ingwe and Access Options, Health Platform benefits are only available at the preferred provider. Preventative care How often? Ingwe and Access Custom, Incentive, Extender and Summit 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 Beneficiaries 60 and older High-risk beneficiaries Once a year Tetanus diphtheria injection All beneficiaries As needed Pneumococcal vaccine Beneficiaries 60 and older As needed High-risk beneficiaries Early detection tests Dental examination (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 40 and older Once every 2 years DEXA bone density scan (radiologist, GP* or specialist) Beneficiaries 50 and older Once every 3 years General physical examination (GP* consultation) Beneficiaries between 21 and 29 Beneficiaries between 30 and 59 Beneficiaries between 60 and 69 Beneficiaries 70 and older Prostate specific antigen (pathologist) Men between 40 and 49 Men between 50 and 59 Men between 60 and 69 Men 70 and older Once every 5 years Once every 3 years Once every 2 years Once a year Once every 5 years Once every 3 years Once every 2 years Once a year Health Assessment (pre-notification not required): All adult beneficiaries Once a year Body Mass Index, Blood pressure test, Cholesterol & blood sugar test (finger prick test) Cholesterol test (pathologist)** All adult beneficiaries Once a year Blood sugar test (pathologist)*** All beneficiaries Once a year Glaucoma test Beneficiaries between 40 and 49 Beneficiaries 50 and older Once every 2 years Once a year HIV test (pathologist) Beneficiaries 15 and older Once every 5 years Maternity programme (subject to registration on the Maternity Management Programme after 8 weeks of pregnancy) Antenatal visits (Midwives, GP* or gynaecologist) Women registered on the programme 3 visits Women registered on the programme 12 visits Urine tests (dipstick) Women registered on the programme Included in antenatal visits Scans (one before 24th week and one after) Women registered on the programme 2 growth scans Women registered on the programme 2 pregnancy scans Paediatrician visits Babies up to 12 months registered on the programme 2 visits in baby s first year Health management programmes Diabetes, Hypertension, HIV/Aids, Oncology, Drug and alcohol rehabilitation, Chronic renal failure, Organ transplants, Cholesterol All beneficiaries registered on the appropriate programme As needed Health line 24-hour 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 R5.5m emergency cover (incl. R optometry, R dentistry and R terrorism cover) A R1 100 co-payment applies per out-patient claim Per beneficiary per 90-day journey In an emergency Please note * On the Custom, Incentive and Extender Options, GP consultations covered under the Health Platform: If you choose the Associated out-of-hospital provider, a 30% co-payment will apply if you do not use an Associated GP ** Covered if Health Assessment results indicate a total cholesterol of 6 mmol/l and above *** Covered for adult beneficiaries if Health Assessment results indicate blood sugar levels are 11 mmol/l and above 18 19

19 Specialised Procedures Specialised Procedures do not necessarily require admission to hospital and are included in the Major Medical Benefit provided that the treatment is clinically appropriate and has been authorised. This benefit covers 19 procedures on the Ingwe and Access Options, and 50 procedures on the Custom, Incentive, Extender and Summit Options. Ingwe Access Custom Incentive Extender Summit Cardiovascular 24-hour halter ECG Angiograms Blood transfusions Coronary angiogram Coronary angioplasty Plasmapheresis ENT Antroscopy Direct laryngoscopy Grommets Myringotomy Nasal scans and surgery Sinus surgery Tonsillectomy General surgery Drainage of subcutaneous abscess Biopsy of breast lump Hernia repairs Lymph node biopsy Excision of small benign and malignant skin or subcutaneous lesions with direct suture or small skin flap Gastro-Intestinal Colonoscopy ERCP Gastroscopy Oesophagoscopy Gynaecology Cervical laser ablation Dilatation and curettage Hysteroscopy Incision and drainage of Bartholin s cyst Marsupialisation of Bartholin s cyst Tubal ligation Neurology 48-hour halter EEG Electro-convulsive therapy Hyperbaric oxygen treatment for decompression sickness Myelogram Obstetrics Childbirth in non-hospital Amniocentesis Oncology Chemotherapy (On Ingwe and Access Options: limited to PMBs at State facilities) Radiotherapy (On Ingwe and Access Options: limited to PMBs at State facilities) Hyperbaric oxygen for radiation necrosis 20

20 Ingwe Access Custom Incentive Extender Summit Ophthalmology Cataract removal Pterygium removal Trabeculectomy Orthopaedic Arthroscopy Bunionectomy Carpal tunnel release Ganglion surgery Renal Dialysis (On Ingwe and Access Options: limited to PMBs at State facilities) Respiratory Bronchography Bronchoscopy Urology Cystoscopy Prostate biopsy Vasectomy Please note: The costs of anaesthetist (if any) are covered only if approved by the Scheme The Specialised Procedures listed attract a co-payment of R850 per authorisation on the Custom Option The Specialised Procedures listed could attract a co-payment on the Incentive and Extender Options, as illustrated below Co-payments for the 17 referral procedures Payable per specialist on the Incentive and Extender Options Procedures performed while admitted to hospital (in-hospital) Procedures done in- or out-of-hospital Arthroscopies, Carpal tunnel syndrome, Back and neck surgery, Functional Nasal and Sinus procedures, Joint replacements, Laparoscopy and Nissen fundoplication Colonoscopy, Sigmoidoscopy, Back & neck treatment, Cystourethroscopy, Treatment for disease of the Conjunctiva, Nail surgery, Gastroscopies, Treatment of Headache, Treatment relating to skin lesions, Treatment of Adult Influenza and Adult Respiratory Tract Infections. Referred by an appropriate GP* R850 co-payment No co-payment if done out-of-hospital R850 co-payment if done in-hospital Not referred by an appropriate GP* R1 350 co-payment R500 co-payment if done out-of-hospital R1 350 co-payment if done in-hospital Please note: Co-payment does not apply to anaesthetist account *Appropriate GP referral: Members may obtain a specialist referral from any GP if they choose Any or State for out-of-hospital provider Members must obtain a specialist referral from an Associated GP if they choose the Associated out-of-hospital provider 21

21 Chronic Benefit 26 Chronic Disease List conditions covered unlimited on the Ingwe, Access, Custom, Incentive, Extender and Summit Options: Addison s disease Asthma Bipolar mood disorder Bronchiectasis Cardiac dysrhythmias Cardiac failure Cardiomyopathy Chronic obstructive pulmonary disease Chronic renal disease Coronary artery disease Crohn s disease (excl. biologicals such as Revellex) Diabetes insipidus Diabetes mellitus Type 1 Diabetes mellitus Type 2 Epilepsy Glaucoma Haemophilia Hyperlipidaemia Hypertension Hypothyroidism Multiple sclerosis (excl. biologicals such as Avonex, subject to protocols) Parkinson s disease Rheumatoid arthritis (excl. biologicals such as Revellex & Enbrel) Schizophrenia Systemic lupus erythematosus Ulcerative colitis On the Incentive Option, an additional 6 conditions are covered, subject to a limit of R6 300 per family per year: Acne (excl. Isotretinoin-containing products such as Roaccutane) ADHD (Attention Deficit Hyperactivity Disorder) Allergic rhinitis Eczema Pemphigus Psoriasis On the Extender Option, an additional 36 conditions are covered, subject to a limit of R6 300 per family per year: Acne (excl. Isotretinoin-containing products such as Roaccutane) ADHD (Attention Deficit Hyperactivity Disorder) Allergic rhinitis Ankylosing spondylitis Aplastic anaemia Benign prostatic hypertrophy Cushing s disease Cystic fibrosis Dermatomyositis Eczema Gout Hypoparathyroidism Immunosupression therapy for transplants Major depression Menopause Motor neuron disease Muscular dystrophy and other inherited myopathies Myasthenia gravis Narcolepsy Obsessive compulsive disorder Oncology - ancillary treatment Osteopenia Osteoporosis Other seizure disorders Paraplegia/Quadriplegia Pemphigus Pituitary microadenomas Post-traumatic stress syndrome Psoriasis Scleroderma Stroke Systemic sclerosis Thromboangiitis obliterans Thrombocytopenic purpura Unipolar disorder Valvular heart disease 22

22 On the Summit Option, an additional 36 conditions, which accumulate to the overall day-to-day limit of R per beneficiary, are covered: Acne (excl. Isotretinoin-containing products such as Roaccutane) ADHD (Attention Deficit Hyperactivity Disorder) Allergic rhinitis Ankylosing spondylitis Aplastic anaemia Benign prostatic hypertrophy Cushing s disease Cystic fibrosis Dermatomyositis Eczema Gout Hypoparathyroidism Immunosupression therapy for transplants Major depression Menopause Motor neuron disease Muscular dystrophy and other inherited myopathies Myasthenia gravis Narcolepsy Obsessive compulsive disorder Oncology - ancillary treatment Osteopenia Osteoporosis Other seizure disorders Paraplegia/Quadriplegia Pemphigus Pituitary microadenomas Post-traumatic stress syndrome Psoriasis Scleroderma Stroke Systemic sclerosis Thromboangiitis obliterans Thrombocytopenic purpura Unipolar disorder Valvular heart disease Chronic benefits are subject to registration and approval. Members on the Ingwe and Access Options Benefits are only available at the chosen preferred provider, and are subject to an entry-level formulary. Members on the Custom, Incentive and Extender Options Depending on the out-of-hospital provider selected, the following applies: Any: You may obtain your chronic prescription and medication from any provider, subject to a reference price list. If you choose to obtain your medication within the reference price list and from Atlas, Clicks, Dis-Chem or Medipost pharmacies, you are assured of no co-payments. If you choose to obtain your medication from outside the reference price list, a co-payment is payable. This co-payment is the cost difference between the reference price and the preferred item. (Reference price is a list of prices per type of medication needed for specific chronic conditions.) Associated: You must obtain your chronic prescription from an Associated GP and your chronic medication from your chosen Courier pharmacy (either Atlas or Medipost), subject to an entry-level formulary. If you choose to obtain your chronic prescription from a non-associated GP, the Scheme will pay 50% of the Momentum Health Rate for the consultation. If you choose to obtain your chronic medication from a pharmacy other than Atlas or Medipost, the Scheme will pay 50% of the formulary price. State: You must choose one of the designated State facilities to obtain your chronic prescription and medication, subject to an entry-level formulary. Members on the Summit Option You have the freedom of choice to obtain your chronic prescription and medication from any provider. No formularies apply. 23

23 Exclusions Notwithstanding the general exclusions mentioned in this paragraph, members are entitled to Prescribed Minimum Benefits (PMBs). Unless otherwise decided by the Scheme (and with the express exception of medicines 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 for by the Scheme, but may be claimed from Savings, or the Health Saver, if available: 1. All costs incurred during waiting periods and for conditions not disclosed. All costs that exceed the annual maximum allowed for the particular category as set out in the detailed benefit specification, for the benefit to which the member is entitled in terms of the rules. 2. Injuries or conditions sustained during wilful participation in a riot, civil commotion, war, invasion, terrorist activity or rebellion. 3. Professional speed contests or professional speed trials (professional defined as where the member s main form of income is derived from partaking in these contests). 4. Illegal behaviour, negligence, or a breach of law. 5. Costs incurred as a result of failure to carry out the instructions of a medical doctor or dentist. 6. Healthcare provider 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 relating to a treatment if the efficacy and safety of such treatment cannot be proved. 9. All costs for operations, medicines, 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 cost of treatment or surgery related to transsexual procedures. 10. Gynaecomastia, blepharoplasty and otoplasty. 11. Breast reduction and breast augmentation. 12. Treatment for obesity. 13. Attempted suicide that exceeds the Prescribed Minimum Benefit limits. 14. Medication not registered by the Medicine Control Council. 15. Costs for services rendered by any institution, nursing home or similar institution not registered in terms of any law. 16. Gum guards and gold used in dentures. 17. Frail care. 18. Travelling expenses, excluding benefits covered by Emergency Evacuation and International Cover. 19. All costs, which in the opinion of the Medical Assessor are not medically necessary or appropriate to meet the healthcare needs of the patient. 20. Appointments that a beneficiary fails to keep. 21. Circumcision and any contraceptive measures or devices. 22. Reversal of vasectomies or tubal ligation (sterilisation). 23. Injuries resulting from narcotic or alcohol abuse, except for the PMBs. 24. Infertility treatment (limited to PMBs in State facilities). 25. The cost of injury and any other related costs as a result of scuba diving to depths below 40 meters and cave diving This is a summary of Momentum Health s exclusions. Full details can be found in the Momentum Health Scheme Rules Contact details: Member call centre: Website: member@momentumhealth.co.za Postal address: PO Box 2338, Durban,

24 Momentum Complementary Products 2011 Momentum offers a range of additional products that adds value through choice. These voluntary complementary products range from a world-class wellness programme, Multiply, to the innovative HealthReturns solution. Product Summary HealthReturns Earn up to R3 600 in as few as two easy steps Multiply Momentum s wellness programme gives you access to discounts and rewards from more than 30 providers Health Saver The easy way to provide for additional healthcare expenses Mobi Enjoy instant access to emergency numbers, claims statements, member details and more on your phone! Health Funder Take care of your post-retirement healthcare Health Waiver Let us look after your loved ones when you can t 25

25 Momentum Complementary Products 2011 HealthReturns R3 600 in cash per adult member can be yours In as few as two easy steps, you can earn up to R3 600 in cash from Momentum. The first step is to undergo a free Health Assessment, the second is to be active. Our HealthReturns programme has been enhanced: In addition to pedometer steps and gym visits, your activity level can be determined through a Fitness Assessment, which can be paid for from your Health Saver HealthReturns are paid every quarter Instead of every calendar year, Health Assessments are valid for 12 months from the date of assessment Members who also belong to Multiply will receive double the HealthReturns if they are on the top two activity levels R1 800 x 2 = R3 600 per adult member, i.e. a couple could earn R7 200 a year! Your level of activity Steps per day on average over a 3-month rolling period Average monthly Multiply gym visits over a 3-month rolling period Fitness assessments (valid for 6 months) Monthly HealthReturns for non-multiply members Level > 12 Excellent R150 R300 Level > 9 to 12 Good R100 R200 Level > 6 to 9 Acceptable R50 R50 Level > 3 to 6 Fair R25 R25 Level Poor R0 R0 *Fitness assessments available at Virgin Life Care and Wellness Coaching Network Monthly HealthReturns for Multiply members Members on the Access, Custom, Incentive, Extender and Summit Options qualify for HealthReturns. Multiply reasons to join Multiply Momentum Health members who also belong to Multiply earn double the HealthReturns for being in the top two activity levels. This means instead of R1 800 you can earn up to R3 600 per adult member per year! By giving you discounted access to wellness partners as well as discounts and rewards from travel and leisure providers, Multiply provides you affordable access to a healthy lifestyle and incentivises you on your journey to wellness. For instance, you can enjoy great discounts on: gym membership (for you, your partner and your children) accommodation, domestic flights and flights to London and the USA movies and magazines Preggi Bellies - specialised cardiovascular programme for expectant moms Adventure Boot Camp for Women outdoors excercise with the luxury of a dedicated trainer GPSs, cameras, binoculars, DVDs, CDs and more 26

26 Health Saver Be prepared for any medical expenses not covered by your option Health Saver is a seamless extension of your medical aid that: is available to all members upon activation allows you to make provision for additional healthcare expenses, such as co-payments, cosmetic surgery and refractive eye surgery incurs no administration fee allows you to choose a monthly amount that suits your pocket and needs pays interest on positive Health Saver balances of R5 000 and more lets you change this amount once a year without having to change your medical aid option gives you the choice of a credit facility or a Pure Saver Mobi Information on the go you should never have to wonder Enjoy instant access to emergency numbers, claims statements, member details and more through your phone! During the course of 2011, Momentum Health will enhance its Mobi offering through the introduction of an interactive mobile website - another first for medical aids in South Africa! By accessing this mobisite through your cellphone, you could: find a healthcare provider closest to any specific location find the number for and contact emergency service providers in a flash use a Help me choose quick needs analysis and quote facility view a summary of your membership, including beneficiaries Multiply and Health Saver status and contributions view your medical Savings account and Health Saver balances see the results of your last Health Assessment (and a reminder of when the next one is due), HealthReturns accumulated to date, as well as next payment date read information about upcoming campaigns and events read general healthcare news and Momentum Health-specific articles All other functionality that is currently part of the MobiCard application, including functionality to fax or proof of membership will be retained. All WAP enabled phones will be able to access the mobisite. 27

27 Health Funder Plan now for your healthcare cover at retirement Make dedicated provision for your post-retirement healthcare costs now via either a retirement annuity or an endowment. The Health Funder: lets you choose your investment fund allows you to select the amount you wish to make provision for and gives you the peace of mind that you will have healthcare cover when you need it most Health Waiver Medical cover in the event of death or disability The Health Waiver ensures that medical cover will be continued in the event of death, functional impairment or critical illness of the principal member and/or spouse. Premiums are calculated according to: age smoking status choice of option, and benefit term 28