Benefits and coverage offered by the Custom option (2025)

This document details the Momentum Custom Option for 2025, optimized for AI readability.

The Custom Option provides comprehensive healthcare coverage, giving you flexibility in choosing your providers and treatment options. Below is a structured breakdown of the key benefits and features of the Custom Option for 2025.

Major Medical Benefits

Hospitalization Coverage

• Providers: Choose any hospital or opt for Associated hospitals.
• Annual Limit: No overall annual limit on hospitalization.
• Specialists:
  • Associated specialists are covered in full.
  • Other specialists are reimbursed up to 100% of the Momentum Medical Scheme Rate.
• Hospital Accounts: Fully covered at the agreed rate with the respective hospital group.
• Co-payment:
  • R1,920 per authorization for most treatments.
  • Exceptions: No co-payment for motor vehicle accidents, maternity confinements, or emergency treatments.
  • Additional co-payments may apply for specialized procedures.

Specialized Procedures and Treatments

• Co-payments:
  • R1,920 for day hospital procedures.
  • R3,840 for acute hospital procedures.

Chronic and Day-to-Day Benefits

Chronic Treatment Coverage

• Providers: Choose from Any, Associated, or State facilities.
• Conditions Covered: 26 chronic conditions listed under Prescribed Minimum Benefits (PMBs).
• Medication: Obtain from any pharmacy or use Medipost courier pharmacy for discounted rates.

Day-to-Day Healthcare

• Services: Includes GP visits, prescribed medications, and preventive care.
• HealthSaver: Available for additional savings on out-of-pocket expenses.

Health Platform Benefit

Overview

• Coverage: Includes day-to-day benefits like preventive screenings and specific check-ups.
• Providers: Choose any provider or opt for Associated providers.
• Additional Support: Momentum HealthSaver+ allows saving for healthcare costs outside the plan's coverage.

Key Benefit Features

Co-Payments for Major Medical Benefits

• Standard Co-payment: R1,920 applies to most authorizations.
• Exceptions: No co-payment for emergency treatments, maternity confinements, or motor vehicle accidents.
• Non-Pre-Authorization: A 30% co-payment applies if pre-authorization is not obtained, or if using a non-designated provider.

Coverage for Chronic Conditions

• Conditions Covered: Includes 26 chronic conditions, as listed in the Chronic Disease List of PMBs.
• Chronic Management Program: Registration and approval required to access benefits.

What Day-to-Day Healthcare coverage is offered in the custom option?

• Providers: Consult any provider, with Momentum HealthSaver available to enhance coverage.
• Covered Services:
  • Mental Health: Psychiatry and psychology, subject to HealthSaver.
  • Dentistry: Basic and specialized treatments are covered, depending on HealthSaver availability.
  • Specialized Treatments like Acupuncture, physiotherapy, and other alternative treatments are subject to HealthSaver balance.

Hospitalization and Specialized Treatment Co-payments

• Hospital Accounts: Fully covered with a co-payment of R1,920 for authorization.
• Specialized Procedures:
  • Day Hospitals: Co-payment of R1,920.
  • Acute Hospitals: Co-payment of R3,840.

Oncology and Organ Transplants

• Oncology: Coverage for chemotherapy up to R300,000 per year, with a 20% co-payment beyond that.
• Organ Transplants: No annual limit for recipient coverage. Donor coverage is limited to specific amounts for cadaver and live donations.

Mental Health and Rehabilitation

• Mental Health: Covered up to R45,300 per beneficiary.
• Rehabilitation: Medical rehabilitation, private nursing, hospice, and step-down facilities covered up to R64,000 per family.

Additional Benefits

Emergency Medical Transport

• Domestic: Unlimited coverage for emergency medical transport by Netcare 911.
• International: R7,660,000 per beneficiary per 90-day journey, including emergency optometry, dentistry, and terrorism cover.

Specialized Treatment Co-payments

• Surgical and Medical Procedures: Specific co-payments apply for certain treatments, such as back surgery or colonoscopies, whether in hospital or at a day facility.

Health Management Programs

• Covered Conditions: Includes chronic renal disease, mental health, organ transplants, HIV/AIDS, and oncology.
• Registration Required: Must be enrolled in the health management program to access these benefits.

Specialized Scans and the Custom Option:

• Coverage:
  • Unlimited coverage for MRI and CT scans.
  • Unlimited coverage for MRCP, whole body radioisotope scans, and PET scans.
• Co-payment:
  • R3,200 per scan.
• Additional Co-payment for Hospitalized Members:
  • Members on the Custom Option who are hospitalized and have a R1,920 co-payment for admission will also need to pay the R3,200 co-payment for specialized scans.
• Co-payment Waivers:
  • Co-payments are waived in cases of emergencies.
  • Members enrolled in the oncology management program will not need to pay co-payments for scans related to cancer treatment, provided the appropriate ICD-10 codes and pre-authorization are used.
• General Requirements:
  • Pre-authorization is required for all specialized scans, even if hospital admission has already been authorized.

Key Points Summarized for the Custom Option:

• The Custom Option provides extensive coverage for these specialized scans.
• However, a significant co-payment is applied per scan, which members must factor into their healthcare planning.
• It is very important to obtain pre-authorisation.
• If a member is in hospital, they will pay both the hospital admission co-payment, and the scan co-payment.

This information should give you a clear understanding of how specialized scans are handled under the Momentum Custom Option.

What is a Doula?

A doula is a trained professional who provides non-medical support during childbirth and the postpartum period. While not involved in medical care, doulas offer emotional and physical assistance to the mother and her partner, ensuring a positive and empowering birth experience. They focus on:

• Emotional support: Reassurance, guidance, and advocacy.
• Physical support: Comfort measures during labor and after birth.
• Postpartum care: Assistance following the delivery.

Criteria for Accessing the Doula Benefit

To qualify for the Doula Benefit, the following criteria must be met:

1. Gynecologist Approval: Your gynecologist must be listed among Momentum Medical Scheme's Associated Specialists.
2. Natural Birth Plan: The birth plan must focus on a natural birth, without surgical interventions or medications.
3. Doula Accreditation: The doula must possess a valid practice number, accredited by recognized organizations such as DOSA (Doulas of South Africa) or WOMBS (Women Offering Mothers Birth Support).

Doula Benefit Overview

The Doula Benefit is available for members enrolled in the Evolve, Custom, Incentive, Extender, and Summit Options. The benefit includes:

Pre-Delivery Consultation (Antenatal Consultation)

• Benefit: One pre-delivery consultation with the doula.
• Value:
  • Evolve and Custom Options: R2,300
  • Incentive, Extender, and Summit Options: R2,400
• Tariff Code: 966072 (recommended for billing)

Post-Delivery Consultation

• Benefit: One post-delivery consultation to address any concerns and provide support.
• Value:
  • Evolve and Custom Options: R2,300
  • Incentive, Extender, and Summit Options: R2,400
• Tariff Code: 966073 (recommended for billing)

Important Notes

• The Doula Benefit is activated once you register for the Maternity Management Programme.
• Registration must be done between the 8th and 20th weeks of pregnancy to ensure access to the benefit.

Contact Information

For more details or assistance with registration, you can contact Momentum Medical Scheme through the following channels:

• Momentum App: Download for easy access to services.
• Webchat: Available on momentummedicalscheme.co.za.
• Email: Send inquiries to [e-mail].
• WhatsApp: Message [phone].
• Phone: Call 0860 11 78 59.

Momentum is here to assist you throughout your pregnancy journey.

Momentum Custom Option - Co-Payment Details:

• Hospital Admissions:
  • Co-payment: R1,920 per authorization.
  • Important Note: This co-payment is specifically stated to apply to the Custom Option.
• In-Hospital Dentistry:
  • Co-payment: R1,920 for maxillo-facial surgery (excluding implants).
• Extraction of Impacted Wisdom Teeth:
  • Co-payment:
    • Day hospitals: R3,450.
    • Other hospitals: R6,500.
• MRI and CT Scans:
  • Co-payment: R3,200 per scan.

General Co-Payment Information (Applicable to Custom Option):

These points apply to all options, including Custom, and are essential to understand:

• Scheme Rules: Co-payments are detailed in the official Scheme Rules, which are approved by the Council for Medical Schemes (CMS). This means these co-payments are formally and legally defined.
• Purpose of Co-Payments: Co-payments are used to:
  • Ensure responsible use of the medical scheme's funds.
  • Discourage overutilization and misuse of healthcare resources.
  • Help to maintain lower and more affordable monthly contributions for members.
• Funding Co-Payments: Members can pay their co-payments using:
  • Funds from their Medical Savings account (if applicable).
  • Funds from their HealthSaver+ account.
  • Direct out-of-pocket payments.
• Pre-authorization:
  • Crucially, pre-authorization must be obtained at least 48 hours before hospital admissions or any specialized treatments.
  • Failure to obtain pre-authorization will result in a 30% co-payment on the claims. This is a significant penalty.
• Emergency Situations: In genuine emergency situations, authorization can be obtained within 72 hours.
• Non-Network Providers: If a member chooses to use hospitals or healthcare providers that are not part of the scheme's network, a 30% co-payment will be applied. This is a strong incentive to use network providers.
• Member Responsibility: It is the member's responsibility to check the specific details of their chosen option (Custom, in this case) to understand which co-payments apply to them.

In Summary:

The Momentum Custom Option has specific co-payments for various medical services. It is essential for Custom Option members to be aware of these costs and to adhere to the pre-authorization requirements to avoid penalties.

Momentum Custom Option - Oncology Management Program Details:

• Annual Limit:
  • R300,000 per year.
  • A 20% co-payment applies to costs exceeding this annual limit.
• Conditions:
  • The Custom Option follows similar rules as the Evolve Option regarding treatment guidelines.
• Providers:
  • State Chronic:
    • Care is provided through ICON providers and Medipost Pharmacy.
    • If non-network providers are used, a 20% co-payment applies to the additional costs.
  • Associated:
    • Any SAOC registered provider and Medipost Pharmacy.
  • Any chronic:
    • Any SAOC provider and any pharmacy.
• Steps to Access Oncology Benefits (General, but Applicable to Custom):
  • Step 1: Consult with a Qualified Oncologist or Hematologist:
    • It's important to ensure the oncologist or hematologist is a network provider for optimal coverage.
  • Step 2: Treatment Plan Submission:
    • The healthcare provider will create a treatment plan and submit it for pre-authorization.
  • Step 3: Documentation Submission:
    • The doctor must send the following to the Oncology Team:
      • Histology, pathology, and/or radiology reports.
      • The treatment plan with the necessary ICD-10 codes.
  • Step 4: Review Process:
    • The Oncology Team will review the request and may request additional information.
  • Step 5: Response Time:
    • Expect a response within 2 to 3 working days regarding the treatment plan approval.
• Treatment Types (General, but Applicable to Custom):
  • Active Treatment:
    • Includes chemotherapy, radiotherapy, and necessary materials.
    • All active treatments require pre-authorization.
  • Non-Active Treatment:
    • Follow-up care and hormonal therapy are covered post-initial treatment.
    • Non-active treatments are also subject to pre-authorization.
• How to Avoid Co-Payments (General Advice, Applicable to Custom):
  • Use network providers.
  • Request generic medications when available.
  • Ensure correct ICD-10 codes are used on claims.
• Exclusions from Oncology Benefits (General, but Applicable to Custom):
  • Treatments outside SAOC/ICON guidelines.
  • Certain medications.
  • Reconstruction surgery.
• Contact Information (General, but Applicable to Custom):
  • Phone: [phone]
  • Email: [e-mail]
  • Website: Visit the Momentum website.
• Support Centers (General, but Applicable to Custom):
  • Cancer Association of South Africa (CANSA).
  • People Living With Cancer (PLWC).
  • Reach for a Dream.
  • The Sunflower Fund.

Key Takeaways for Custom Option Members:

• The Custom Option has a R300,000 annual limit for oncology benefits.
• Adhere to the SAOC/ICON guidelines.
• Using network providers is important to avoid extra costs.
• Pre-authorisation is very important.
• Understanding the treatment types, and exclusions is very important.

Momentum Custom Option - Health Platform Benefits:

General Information:

• Health Platform Benefits are designed to support members by promoting health awareness, improving quality of life, and offering preventative care.
• These benefits are fully covered by the Scheme.
• While most benefits don't require pre-notification, some do.

Pre-Notification:

• The Custom Option requires pre-notification for:
  • Preventative dental care.
  • Pap smears.
  • General physical examinations.
  • HIV tests.
• Pre-notification can be managed via:
  • The Momentum App.
  • Web chat on the Momentum website.
  • Visiting the Momentum website.
  • WhatsApp.
  • Calling 0860 11 78 59.

Preventative Care Benefits (Custom Specifics):

• Baby Immunizations:
  • Coverage is provided.
• Flu Vaccines:
  • Coverage is provided.
• Tetanus Diphtheria Injection:
  • Coverage is provided.
• Pneumococcal Vaccine:
  • Eligibility: Beneficiaries aged 60 and older, and high-risk individuals.
  • Frequency: Once a year.
• Early Detection Tests:
  • Preventative Dental Care:
    • Coverage: Up to R380 per beneficiary at dentists, dental therapists, or oral hygienists.
    • Frequency: Once a year.
    • Pap Smear Consultation:
      • Eligibility: Women aged 15 and older.
      • Frequency: Once a year.
      • Consultation with a nurse, GP, or gynecologist.
    • Pap Smear (Pathologist):
      • Eligibility: Women aged 15 and older.
      • Frequency: Once a year (standard or liquid-based cytology) or every three years (HPV PCR screening).
    • Mammogram:
      • Eligibility: Women aged 38 and older.
      • Frequency: Every two years.
    • DEXA Bone Density Scan:
      • Eligibility: Beneficiaries aged 50 and older.
      • Frequency: Once every three years.
    • General Physical Examination:
      • Eligibility:
        • Aged 21 to 29: once every five years.
        • Aged 30 to 59: every three years.
        • Aged 60 to 69: every two years.
        • Aged 70 and older: once a year.
    • Prostate Specific Antigen (Pathologist):
      • Eligibility: Men aged 40 and older.
      • Frequency: Based on age.
    • Health Assessment:
      • Coverage: Tests for blood pressure, cholesterol, blood sugar, height, weight, and waist circumference.
      • Frequency: Once a year for principal members and adult beneficiaries.
    • Cholesterol and Blood Sugar Tests (Pathologist):
      • Frequency: Once a year for principal members and adult beneficiaries.
    • Glaucoma Test:
      • Eligibility: Beneficiaries aged 40 to 49 (every two years), and 50 and older (annually).
    • HIV Test (Pathologist):
      • Eligibility: Beneficiaries aged 15 and older.
      • Frequency: Once every five years.

Maternity Programme (Custom Specifics):

• Registration:
  • Women must register between 8 to 20 weeks of pregnancy to access the maternity program.
• Key Benefits:
  • Doula Benefit: Two visits per pregnancy.
  • Antenatal Visits: Twelve visits.
  • Antenatal and Postnatal Classes: 18-month online subscription or face-to-face classes.
  • Lactation Specialist Consultation: Initial online consultation covered. Follow-up consultations may also be covered.
  • Nurse Home Visit: Available the day after returning from the hospital, with additional visits at specified intervals.
  • Urine Tests (Dipstick): Included in antenatal visits.
  • Pathology Tests: Various tests covered, including antiglobin, platelet count, and rubella antibody tests.
  • Pregnancy Scans: Coverage for up to three-dimensional and four-dimensional scans at the rate of two-dimensional scans.
  • Paediatrician Visits: Two visits during the first year.

Health Line (Applicable to Custom):

• A 24-hour emergency health advice line is available.

Momentum Custom Option - Specialised Procedures and Treatments:

• General Coverage:
  • Coverage applies to specialised procedures and treatments under the Major Medical Benefit.
  • Coverage is the same whether the procedure is carried out in a hospital or an out-of-hospital setting.
  • Pre-authorization is mandatory for all procedures and treatments.
• Anaesthetist Costs:
  • Coverage Limit: R620 per procedure.
  • Pre-authorization is required.
  • Additional Costs: Coverage for anaesthetist costs will only apply if deemed clinically appropriate for other procedures.
• Co-payments for Specialised Procedures:
  • Co-payment: R1,920 per authorization.
  • Note: This co-payment is "subject to variation for specific procedures." This means that certain specialised procedures may have different co-payment amounts. It is very important to contact Momentum to get the correct co-payment amounts.
  • It is stated that the full co-payment document should be consulted for more information.
• +HealthSaver Product:
  • The +HealthSaver product is available to the Custom option member, as it is available to all Momentum Medical Scheme members.
  • It is an optional complementary product.
  • It is important to understand that +HealthSaver is a product of Momentum, and not the Momentum Medical Scheme.
  • Membership in the Momentum Medical Scheme does not require enrollment in the +HealthSaver product.
• Important Notes:
  • The provided document does not cover all procedures and treatments available under the Scheme.
  • For clarification on whether a specific procedure or treatment is covered, members must contact Momentum directly.
  • It is important to allways get pre-authorisation.

Key Takeaways for Custom Option Members:

• Pre-authorization is crucial for all specialised procedures and treatments.
• Anaesthetist costs are limited to R620 per procedure.
• A R1,920 co-payment generally applies per authorization, but this can vary.
• The +HealthSaver product is an option, but not a requirement.
• Direct contact with Momentum is essential for specific procedure coverage and co-payment details.

Momentum Custom Option - Maternity Program Details:

1. Registration:

• Registration can begin from the eighth week of pregnancy.
• Registration methods:
  • Momentum App.
  • Momentum Medical Scheme website (momentummedicalscheme.co.za).
  • WhatsApp.
  • Phone [phone]).
• Required information:
  • Email address.
  • Name, surname, and practice number of GP, gynecologist, registered midwife, or doula.
  • Complete medical, surgical, and obstetric history.
  • Expected delivery date.

2. Partnership with BabyYumYum:

• Momentum partners with BabyYumYum for pre- and post-natal support.
• Registration includes consent to enroll in the MyMomentum BabyYumYum program.
• BabyYumYum sends a welcome message with benefit details.

3. Maternity Program Benefits (Custom Specific):

• Antenatal Visits:
  • Coverage for up to twelve antenatal visits.
  • Includes urine dipstick tests (tariff code 4188) at a GP, gynecologist, or registered midwife.
• Scans:
  • Coverage for two pregnancy scans.
  • 3D and 4D scans covered at the 2D scan rate (tariff codes 3615 and 3617).
• Pathology Tests:
  • One of each test per pregnancy:
    • Blood group (3764).
    • Creatinine (4032).
    • Full blood count (FBC) (3755).
    • Glucose strip (4050).
    • Hemoglobin estimation (3762).
    • Rhesus factor (3765).
  • Twelve urinalysis tests (4188) per pregnancy.
  • Urine tests covered if requested by the doctor:
    • Microscopic exams (3867).
    • Antibiotic susceptibility (3887).
    • Culture (3893).
• Maternity Coaches:
  • Access to trained midwifery maternity coaches via telephone.
  • Coaches provide advice and support regarding pregnancy and newborns.
  • Regular contact for high-risk pregnancies.
• Doula Benefit:
  • Two doula visits per pregnancy.
  • Conditions:
    • Doula accredited by DOSA or WOMBS.
    • Gynecologist is an Associated Specialist.
    • Natural birth plan.
  • Doula benefit must be authorized during maternity benefit registration.
• Audiology, Circumcision, and Physiotherapy:
  • Not routinely covered.
  • Paid from Day-to-day benefits or HealthSaver+ (if available).
  • Circumcision covered for medical reasons with pre-authorization.
• Baby Immunizations:
  • Covered for children up to six years, as per the Department of Health schedule.
  • Once the baby is born, pre-authorisation for the immunizations is required.
• Pediatrician Visits:
  • Coverage for two pediatrician visits during the baby’s first year.
• BellyBabies Benefit:
  • Access to an online antenatal course (50 videos) and lactation specialist video consultations.
  • Discount available to Momentum Medical Scheme members.
  • Paid from HealthSaver+ funds (if available).
• Hello Doctor:
  • 24/7 access to doctors via phone or text.
  • Accessible through the Momentum App or website.
  • Hello Doctor app available.
  • Contact information for Hello Doctor is provided.
• Associated Specialists:
  • Momentum has contracts with Associated Specialists (gynecologists, pediatricians, anesthetists).
  • These specialists charge negotiated rates, minimizing out-of-pocket costs.
  • Information on specialist availability is provided.
• Authorization for Confinement:
  • Pre-authorization is required.
  • Contact via email, WhatsApp, or phone [phone]) within 30 days of delivery.
  • Inform of admission date changes within 48 hours.
• Adding Baby to Membership:
  • Baby is not automatically added to the scheme.
  • Newborn registration form required.
  • First month’s contribution waived if registered within 30 days.
  • Employer approval required for employer-paid contributions.
• Nurse Home Visit:
  • Nurse home visit on the day after returning home from hospital, and an additional visit two weeks later.
• BabyYumYum benefit:
  • Access to expert advice from the BabyYumYum portal.
• Summary of Custom Option Maternity Benefits:
  • Antenatal visits - 12 visits.
  • 2 pregnancy scans, 3D/4D covered as 2D.
  • Two doula visits.
  • Baby immunizations up to age 6.
  • Nurse home visits (initial and 2 weeks later).
  • Two pediatrician visits.
  • Hello Doctor+.
  • BellyBabies is subject to HealthSaver+.

4. General Information:

• Momentum Medical Scheme is separate from Momentum Group.
• Momentum products (e.g., Momentum Multiply) are not medical scheme benefits.
• Contact information for the medical scheme is provided.

Momentum Custom Option - Chronic Benefit Details:

• Provider:
  • Members on the Custom Option can choose from:
    • Any provider.
    • Associated providers.
    • State providers.
• Conditions Covered:
  • Covers the 26 conditions listed in the Chronic Disease List (PMB).
• Annual Limit:
  • There is no annual limit for the 26 PMB conditions (subject to the formulary).
• How to Obtain Chronic Benefits:
  • Provider:
    • State
  • Chronic Prescription:
    • From any GP.
  • Chronic Medication:
    • From any pharmacy (subject to formularies).
  • Preferred Medication:
    • No co-payment if medication is within the Momentum Medical Scheme Reference Price.
  • Non-Preferred Medication:
    • A 15% co-payment applies to the member for medications exceeding the reference price.
  • Non-Medipost Pharmacy:
    • The scheme covers 50% of the formulary price, and the member pays the balance.
• Chronic Medication Registration Process:
  • For Freedom-of-choice or Any Chronic Provider:
    • The treating doctor or pharmacist must contact Momentum Medical Scheme at 0860 11 78 59 to request registration.
    • A chronic benefit consultant will assess the request and approve or decline it via phone.
    • Momentum may request relevant tests from the provider.
    • After approval, the member can collect medication from any pharmacy.
    • A renewed prescription must be submitted every 6 months.
• Summary of Formulary Structure:
  • Basic/Standard/Extended Formulary:
    • Applies to the Custom Option.
    • Preferred Products: Momentum Reference Price applies.
    • Non-Preferred Products: Co-payment applies (15% for Custom).
• FAQs:
  • What is a Formulary?
    • A list of medications covered under the specific plan, prescribed by the doctor for chronic conditions.
  • What is the Momentum Medical Scheme Reference Price?
    • The maximum amount reimbursed by Momentum Medical Scheme for a medication. Co-payments may apply if medication exceeds this price.
• Clinical Registration Criteria:
  • The 26 PMB chronic conditions are listed, with specific diagnosis requirements. Example:
    • Addison’s Disease: Diagnosis by a specialist required.
    • Asthma (adult/child): Confirmed by GP or pediatrician.
    • Cardiac Failure: Diagnosis confirmed by a specialist.
    • Chronic Renal Disease: Diagnosis with lab results.
    • Diabetes Insipidus: Diagnosis by a specialist.
  • For the full list of conditions and registration requirements, members are directed to the clinical guidelines provided by Momentum Medical Scheme.

Key Takeaways for Custom Option Members:

• Members have flexibility in choosing their chronic medication providers.
• Understanding the formulary and reference pricing is crucial to minimize out-of-pocket expenses.
• The registration process requires proactive involvement from the treating doctor or pharmacist.
• Renewal of prescriptions is necessary every 6 months.
• It is very important to understand that there are different co-payment amounts for preferred and non preferred medication.

Momentum Custom Option - Procedures and Treatments Details:

• General Coverage:
  • Coverage applies to procedures and treatments under the Major Medical Benefit.
  • Coverage applies whether the procedure is performed in or out of hospital.
  • Pre-authorization is mandatory for all procedures and treatments.
  • The document provided does not cover all procedures and treatments, and Momentum must be contacted for clarification.
• Anaesthetist Costs:
  • For gastroscopies and colonoscopies, anaesthetist costs are covered up to R590.
  • Pre-authorization is required.
  • For other medical procedures, anaesthetist costs are covered if deemed clinically appropriate.
• Co-payments for Specialised Procedures:
  • A co-payment of R1,830 per authorization may apply.
  • This co-payment might differ for certain procedures.
  • The document linked above should be consulted for further details.
• HealthSaver Product:
  • HealthSaver is offered as a complementary product.
  • It is a product of Momentum Metropolitan Holdings Limited (Momentum), which is separate from the Momentum Medical Scheme.
  • It is not a medical scheme benefit.
  • Membership in the Momentum Medical Scheme does not require enrollment in HealthSaver.

Key Takeaways for Custom Option Members:

• Pre-authorization is essential for all procedures and treatments.
• Anaesthetist cost for gastroscopies and colonoscopies is limited to R590.
• A R1830 co-payment is generally applicable, but can change per procedure.
• HealthSaver is a separate, optional product.
• Contacting Momentum for procedure specific information is very important.

Momentum Custom Option - Oncology Management Program Details:

1. Benefit Limits:

• Overall annual limit: R300,000 per beneficiary per year.
• A 20% co-payment applies once this limit is reached.
• Momentum Medical Scheme Reference Pricing applies to chemotherapy and adjuvant medications.
• SAOC Tier 1 benefits are available for both Associated and Any Options, contingent upon approval.
• In cases that meet specific clinical criteria for exception management, certain specialized oncology medicines and treatments may be accessed on Tier 2 and Tier 3, up to a sub-limit of R200,000 within the overall oncology limit.

2. Your benefit option and chronic provider determine which specialists and pharmacy you may use

• Custom, Incentive, and Extender – State chronic provider: For these options, oncologists, haematologists, and pharmacies must be sourced from the ICON Network of oncology providers. Treatment is subject to the ICON Essential Treatment Protocols. As with the Evolve option, using a non-network provider will result in a 20% co-payment for all oncology-related expenses, highlighting the importance of staying within the network.
• Custom, Incentive, and Extender – Associated chronic provider: Members have the flexibility to select any SAOC registered oncology provider and utilize Medipost pharmacy for their medications, allowing for a more personalized approach to care.
• Custom, Incentive, and Extender – Any chronic provider: Members enjoy the freedom to choose any SAOC registered oncology provider and any pharmacy for their medications, providing maximum flexibility in their treatment options.

3. Active treatment

• Active treatment refers to the phase during which a patient undergoes chemotherapy, radiotherapy (radiation), or brachytherapy, depending on their specific diagnosis and treatment plan. All treatments are approved in accordance with the SAOC or ICON guidelines, Scheme Rules, and the design of the benefits, ensuring that members receive the care they need.
  • Chemotherapy: This treatment may include adjuvant chemotherapy, which is administered to eliminate any remaining cancer cells after surgery, thereby significantly reducing the risk of recurrence. Alternatively, palliative chemotherapy may be utilized to alleviate symptoms and slow the progression of the disease. The pricing for chemotherapy and adjuvant medications follows the Momentum Medical Scheme Reference Pricing.
  • Radiotherapy utilizes high-energy rays to target and destroy cancer cells. While this treatment can also affect healthy cells, it is important to note that cancer cells generally lack the ability to repair themselves, whereas healthy cells typically can recover after treatment. Palliative radiotherapy may also be employed to provide relief from symptoms.
  • All materials necessary for administering active treatment, such as drips, needles, and any supportive treatments, are covered under the active treatment benefits, ensuring that patients do not face additional financial burdens.
  • The comprehensive treatment plan includes consultations, infusion fees, pathology, radiology, and all medications necessary for effectively treating the disease, providing a holistic approach to cancer care.
  • Consultations with the oncologist are fully covered at 100% of the Momentum Medical Scheme Rate, provided that you utilize the applicable network provider according to your benefit option, ensuring that members have access to expert care without added costs.
  • Pathology tests related to your condition will be covered at 100% of the Momentum Medical Scheme Rate if they are requested by the treating network doctor and are pre-authorized, further emphasizing the importance of following the correct procedures.
  • Radiology services related to your condition will also be covered at 100% of the Momentum Medical Scheme Rate if requested by the treating network doctor and pre-authorized. This coverage includes basic x-rays and scans, as well as specialized radiology services such as CT, MRI, and nuclear scans, although a co-payment may apply for specialized services. It is crucial to remember that scans not directly related to cancer will not be covered under the oncology benefit.

4. Non-active treatment

• The Momentum Medical Scheme provides coverage for follow-up (non-active) treatment after the initial treatment is completed, contingent upon pre-authorization. This category of treatment includes various important services:
  • Hormonal therapy, which is applicable for different cancer types, such as breast and prostate cancer, and is covered as per SAOC and ICON guidelines, ensuring that patients receive the necessary ongoing care.
  • Follow-up care encompasses consultations, pathology, and radiology as previously mentioned, allowing for continuous monitoring of the patient's condition.
  • Pain management is also included for patients experiencing extensive disease spread, ensuring that comfort remains a priority during treatment.
  • Lymph drainage (physiotherapy) conducted by an accredited therapist is covered, provided that the complication arises as a result of radiation and axillary clearance, emphasizing the importance of comprehensive care.
  • Support from registered clinical coaches is available to assist patients and their families with the necessary follow-up care, providing guidance and resources during the recovery process.

5. What is not covered from the oncology benefit?

• Treatments that do not fall within the parameters established by the SAOC or ICON guidelines and formularies, as well as the Scheme Rules, will not be covered. This ensures that all provided services maintain a high standard of care.
• Acute medications such as antibiotics, antidepressants, anxiety medications, sleeping tablets, vitamins, and homeopathic remedies are not covered under oncology benefits but may be claimed from available Day-to-day benefits, allowing for some flexibility in treatment options.
• External breast prostheses, specialized bras, stoma products, and oxygen therapy are covered under the Major Medical Benefit, subject to applicable limits based on your benefit option, ensuring that members receive necessary support.
• Reconstruction surgery is not included within the oncology limit but is funded through the Major Medical Benefit. In cases of breast cancer, if the mastectomy was not performed while the member was enrolled in the Momentum Medical Scheme, we will require supporting documentation to process claims.
• Hospice and home-based nursing care benefits are covered under the relevant Major Medical Benefit; however, pre-authorization is necessary in consultation with the treating oncologist. Limits will apply based on your benefit option. It is important to note that hospice and private nursing care are not covered under the Ingwe Option.
• Mental health benefits related to the impact of oncology treatment must be authorized. If approved, treatment will be covered under the mental health benefit, subject to the limits applicable to your benefit option, recognizing the emotional toll that cancer can take.
• Treatment for chronic conditions that arise as a result of medication will be subject to your chronic benefit, ensuring that ongoing health issues are addressed.
• Wigs are funded through available Day-to-day benefits, helping to alleviate some of the physical challenges associated with cancer treatment.

6. How to avoid co-payments

• To minimize co-payments, it is advisable to utilize doctors and pharmacies that are part of your benefit option’s networks. Collaborating with your treating doctors will help ensure that the treatment provided aligns with the appropriate guidelines and formularies, reducing unexpected costs.
• Request that your doctor consider prescribing generic medications. While your doctor will ultimately determine the appropriateness of generic medications, this choice may influence the funding for the prescribed medicine, potentially lowering out-of-pocket expenses.
• Ensure that all treatment remains within the benefit limits set for your specific option to avoid incurring additional costs, which can add financial stress during an already challenging time.
• Make sure that the correct ICD-10 codes related to your cancer diagnosis are included on all claims submitted to us, including those for pathology and radiology. It is advisable to discuss this with your doctors to ensure they submit claims with the correct ICD-10 codes, as per the treatment plans submitted or as provided when authorized.

7. When does oncology qualify as a Prescribed Minimum Benefit?

• It is important to understand that not all cancer treatments are classified as Prescribed Minimum Benefit treatments. However, this does not imply that there will be no coverage for cancer treatments that do not qualify as Prescribed Minimum Benefits, as oncology benefits still apply to non-Prescribed Minimum Benefit cancer treatments, with the exception of the Ingwe Option, which only covers Prescribed Minimum Benefits.

8. Once the oncology limits for cancer treatment have been exceeded, the Scheme will cover 80% of the benefit for the remainder of the year.

• This means that you, as the member, will be responsible for 20% of the associated costs, ensuring that you continue to receive necessary care even after reaching your limit.

9. Contact details

• If you have any questions or require further information, please do not hesitate to reach out to us. We are here to help you navigate your healthcare needs during this difficult time.
  • Member contact centre: 0860 11 78 59 – You can either WhatsApp or call us for assistance.
  • Email: [e-mail]
  • Web: momentummedicalscheme.co.za

10. Support centres for oncology patients

• Cancer Association of South Africa (CANSA)
  • Toll-free: 0800 22 66 22
  • Email: [e-mail]
• People Living With Cancer (PLWC)
  • Toll-free: 0800 03 33 37 / 021 565 0039
  • Email: [e-mail]
• Reach for a Dream
  • Tel: [phone]
  • Email: [e-mail]
  • Web: reachforadream.org.za
• The Sunflower Fund
  • Toll-free: 0800 12 10 82
  • Web: sunflowerfund.org.za

11. Glossary of terms used in this document

• Term
  • Momentum Medical Scheme Reference Pricing: This term refers to the maximum amount that the Scheme will reimburse for a specific medication. If a medication costs more than the established reference pricing, you will be responsible for covering the difference in cost, ensuring transparency in your healthcare expenses.
  • Generic medication: A generic drug is a pharmaceutical product that is equivalent to a brand-name drug in terms of dosage, strength, route of administration, quality, performance, and intended use, but does not carry the brand name. The active pharmaceutical ingredient is the same as the original, although there may be differences in manufacturing processes, color, taste, and packaging, making generics a cost-effective alternative.
  • ICD-10 code: This coding system is used to document various medical records, including diseases, symptoms, abnormal findings, and external causes of injury. Essentially, it is your diagnosis code, which is crucial for accurate billing and treatment tracking.
  • ICON: This stands for the Independent Clinical Oncology Network, which plays a vital role in providing standardized care across various oncology providers.
  • Oncologist: An oncologist is a medical doctor who specializes in diagnosing and treating cancer, ensuring that patients receive expert care tailored to their specific needs.
  • Prescribed Minimum Benefits: Prescribed Minimum Benefits (PMBs) refer to a specific list of benefits that all medical schemes in South Africa are mandated to provide coverage for, as outlined in the Medical Schemes Act 131 of 1998 and its accompanying regulations. To qualify for these benefits:
    • Your medical condition must be included in the defined list of Prescribed Minimum Benefit conditions.
    • The treatment required must align with the treatments specified in the defined benefits.
    • You must utilize the Scheme’s Designated Service Providers, ensuring that you receive care that meets the established standards.
    • If you choose to use non-designated service providers voluntarily, the Scheme will cover benefits up to the Momentum Medical Scheme Rate, and relevant co-payments will be applicable. In cases of emergency medical conditions where non-designated service providers are used, it is considered involuntary, and co-payments will be waived. If your medical condition and treatment do not meet the criteria for accessing these benefits, we will process claims according to the benefits available on your selected benefit option.
  • SAOC: This stands for the South African Oncology Consortium, which is instrumental in establishing guidelines and protocols for oncology care.

Momentum Custom Option - Mental Health Benefits Details:

1. General Information:

• Mental health disorders encompass a wide range of diagnoses, including schizophrenia, depression, intellectual disabilities, and substance abuse disorders.
• Bipolar affective disorder and schizophrenia are classified as 26 Chronic Disease List (PMB) conditions.
• Depression, substance abuse rehabilitation, and acute stress disorder are classified as 271 PMB conditions.
• Benefits are accessible through Designated Service Providers (DSPs), in alignment with the benefit option.
• Pre-authorisation is required for both inpatient and outpatient benefits.
• A treatment plan from the treating physician is necessary.
• Educational assessments, disability evaluations, forensic investigations, and marriage counseling are not covered.

2. Bipolar Affective Disorder & Schizophrenia (26 CDL PMB):

• Medication:
  • Benefits are available through applicable chronic network providers.
• Doctors, Pathology, and Radiology:
  • Subject to the treatment plan.

3. Depression, Acute Stress Disorder, Alcohol and Drug Rehabilitation (271 PMB):

• Medication:
  • Subject to HealthSaver+ if available.
• In-hospital:
  • 21 days at a private facility DSP.
  • Subject to a mental health limit of R43,000 per beneficiary.
  • Alcohol and drug rehabilitation included within this 21-day limit (must complete full 21 days at a SANCA facility).
• Out-of-hospital:
  • 15 outpatient psychotherapy consultations.
  • This is not in addition to the in-hospital benefit and limit.

4. Eligibility:

• Individuals diagnosed with a mental health condition by their family doctor, specialist psychiatrist, or psychologist are eligible.

5. Registration Process:

• Obtain a treatment plan from the treating physician/facility.
• For hospitalization, pre-authorisation is required. Email [e-mail], use WhatsApp, or call 0860 11 78 59. Provide:
  • Diagnosis and ICD-10 code.
  • Current clinical condition.
  • Estimated length of stay (if applicable).
  • Completed assessment or DSM form.
  • Treatment plan with duration and tariff codes.
  • For children under 14, a referral letter from a GP, pediatrician, or psychiatrist is required.
• Submit a letter of motivation or DSM form for in-hospital benefits for depression, substance abuse, and acute stress disorder to [e-mail].
• For outpatient psychotherapy (PMB conditions), submit a letter of motivation or treatment plan to [e-mail].
• Chronic mental health benefits (bipolar affective disorder, schizophrenia) registration initiated by the treating psychiatrist through the chronic registration process. For chronic medication registration, call 0860 11 78 59.

6. Glossary of Terms:

• Chronic Disease List (CDL): 26 chronic conditions mandated for coverage.
• Designated Service Provider (DSP): Network of providers for PMB conditions.
• DSM form: Diagnostic assessment and treatment plan report.
• ICD-10 code: Diagnosis coding system.
• Prescribed Minimum Benefits (PMBs): Mandated benefits, including 271 diagnoses and 26 chronic conditions.
• Tariff codes: Healthcare provider billing codes.
• HealthSaver+: Voluntary supplementary product.

Key Takeaways for Custom Option Members:

• Bipolar and Schizophrenia medication is covered via the chronic medication benefit.
• Depression and substance abuse medication is only covered via the Healthsaver+ account.
• In hospital cover for depression and substance abuse is limited to 21 days with a monetary limit.
• Out patient cover for depression and substance abuse is limited to 15 consultations.
• Pre-authorisation is extremely important.
• Using DSP providers will help avoid extra costs.

Momentum Custom Option - HIV/Aids Management Program Details:

1. General Information:

• Momentum Medical Scheme provides comprehensive management and treatment for individuals living with HIV/Aids.
• The goal is to ensure access to suitable medical care, promoting wellness, prevention, and ongoing support.
• Members must enroll in the Lifesense HIV program to access HIV/Aids treatment benefits.

2. Registration:

• Prompt enrollment is essential after a positive HIV test result.
• The HIV Elisa test is covered under the Health Platform Benefit.
• Pregnant members are strongly encouraged to register early.
• Registration is confidential.
• Either the member or their treating physician can contact Lifesense.
• Lifesense collaborates with healthcare providers to develop a tailored treatment plan.
• Members receive ongoing education, support, and access to antiretroviral (ARV) medication.
• The Scheme manages annual benefit limits.

3. Benefits for Post-Exposure Prophylaxis (PEP) Treatment:

• Members with potential HIV exposure (e.g., needle stick injury, sexual assault) can access PEP treatment.
• Contact Lifesense to access PEP treatment.

4. Where to Get Anti-Retroviral Medication (ARV):

• For the Custom Option, there are several avenues available for obtaining medication:
  • Any chronic provider - Any pharmacy.
  • Associated chronic provider - Medipost pharmacy.
  • State chronic provider - Medipost pharmacy.

5. Lifesense Contact Details:

• Tel: [phone]
• Fax: [phone]

Key Takeaways for Custom Option Members:

• Enrollment in the Lifesense HIV program is mandatory for HIV/Aids treatment benefits.
• Members have flexibility in obtaining ARV medication, depending on their chosen chronic provider.
• PEP treatment is available for potential HIV exposure.
• Lifesense provides comprehensive support and treatment management.
• Confidentiality is assured.

Momentum Custom Option - Day-to-day Benefit Details:

• General Information:
  • The Day-to-day Benefit is designed to assist members with routine medical expenses, including healthcare professional visits and prescribed medications.
• Accessing Benefits:
  • Members who choose the Custom Option have the opportunity to enhance their coverage by adding the Momentum HealthSaver+, a supplementary product that helps fund their day-to-day healthcare expenses. This option provides additional flexibility and support for managing healthcare costs.
• Claims Submission:
  • Claims can be submitted via:
    • Momentum App (photograph of the claim).
    • Email: [e-mail].
    • Postal service: Momentum Medical Scheme Claims, PO Box 2338, Durban, 4000.
  • Required information for claim submission:
    • Membership number.
    • Principal member’s name and surname.
    • Patient’s name and surname.
    • Treatment date.
    • Amount charged.
    • Relevant ICD-10 code.
    • Tariff code and/or Nappi code.
    • Service provider’s name and practice number.
    • Proof of payment (if applicable).
• HealthSaver+:
  • The Healthsaver+ is a seperate product that can be added to the custom option, to help fund day to day expenses.

Key Takeaways for Custom Option Members:

• The Custom Option allows for the addition of the Momentum HealthSaver+ to supplement day-to-day healthcare expenses.
• Multiple methods are available for claims submission.
• Providing complete and accurate information is crucial for efficient claims processing.
• The Healthsaver+ is a add on product.

Momentum Custom Option - Dental Benefits Details:

3. Custom Option

• 3.1 Basic Dentistry:
  • Benefit: Basic dental services.
  • Coverage: Payable from HealthSaver+, subject to available funds.
• 3.2 Out-of-Hospital Specialized Dentistry (Bridges, Crowns):
  • Benefit: Specialized dental services.
  • Coverage: Payable from HealthSaver+, subject to available funds.
  • Wisdom Teeth Extraction:
    • Coverage: Anaesthetist and dental specialist accounts covered under Major Medical Benefit (100% of Momentum Medical Scheme Rate).
    • Co-payment: R1,830.
    • Requirement: Pre-authorization.
• 3.3 In-Hospital Dental and Oral Benefits:
  • Maxillo-facial Surgery (Excluding Implants) and General Anaesthesia (Children under 7):
    • Anaesthetist: 100% of Momentum Medical Scheme Rate.
    • Hospital: Full at negotiated rate.
    • Dental, Specialist, Maxillo-facial Surgeon: Payable from HealthSaver+, subject to available funds.
    • Co-payment: R1,830 per authorization.
    • Requirement: Pre-authorization.
  • Dentistry Related to Trauma:
    • Hospital: Full at negotiated rate.
    • Anaesthetist, Dentist, Specialist, Maxillo-facial Surgeon: 100% of Momentum Medical Scheme Rate.
  • Extraction of Impacted Wisdom Teeth:
    • Hospital: Major Medical Benefit.
    • Co-payment: R3,300 (day hospitals), R6,150 (other hospitals) per authorization.
    • Dental, Specialist, Maxillo-facial Surgeon, Anaesthetist: 100% of Momentum Medical Scheme Rate (Major Medical Benefit).
  • Implants and Other In-Hospital Dental Treatment:
    • Benefit: Not covered.
    • Coverage: Payable from HealthSaver+, subject to available funds.

Key Takeaways for Custom Option Members:

• Basic and specialized out-of-hospital dental services are covered by the HealthSaver+ account.
• Wisdom teeth extraction performed in a doctors office, has a R1830 co-payment, and the anaesthetist and dental specialist is covered at 100% of the Momentum Medical Scheme Rate.
• In hospital Maxillo-facial Surgery (Excluding Implants) and General Anaesthesia (Children under 7) has a R1830 co-payment, the anaesthetist is covered at 100% of the Momentum Medical Scheme Rate, and the hospital is covered at the negotiated rate. The dental, specialist, and maxillo-facial surgeon is paid from the HealthSaver+ account.
• In hospital dentistry related to trauma, the hospital is covered at the negotiated rate, and the anaesthetist, dentist, specialist, and maxillo-facial surgeon is covered at 100% of the Momentum Medical Scheme Rate.
• In hospital extraction of impacted wisdom teeth, the hospital is covered by the major medical benefit, with a large copayment. The dental specialist, maxillo-facial surgeon, and anaesthetist are covered at 100% of the momentum medical scheme rate.
• In hospital implants and other in hospital dental treatment is not covered by the medical aid, and is paid from the HealthSaver+ account.
• Pre-authorisation is very important.

Momentum Custom Option - Benefit Exclusions Details:

General Exclusions (Applicable to All Options, Including Custom):

• Waiting Periods and Undisclosed Pre-existing Conditions:
  • Costs incurred during waiting periods and for conditions not disclosed during membership application.
• Exceeding Annual Maximum Limits:
  • Costs exceeding annual maximum limits as defined in Annexure B of the Scheme Rules.
• Injuries from Riots, Warfare, Terrorism, etc.:
  • Injuries or health conditions resulting from intentional participation in riots, civil disturbances, warfare, invasions, terrorist acts, or rebellions.
• Professional Speed Contests/Trials:
  • Expenses related to professional speed contests or trials.
• Unregistered Healthcare Providers:
  • Services from healthcare providers not registered with appropriate professional bodies.
• Recuperative Holidays:
  • Costs associated with holidays for recuperative purposes.
• Unsubstantiated Treatments:
  • Costs for treatments with unsubstantiated efficacy and safety.
• Cosmetic Procedures (Non-Medical):
  • Expenses for cosmetic procedures not linked to a medical condition, accident, or disease (including transsexual procedures).
• Obesity Treatments:
  • Costs related to obesity treatments (unless otherwise specified).
• Suicide Attempts (Limited Coverage):
  • Suicide attempts exceeding three days of hospital management or six outpatient visits.
• Specific Cosmetic Procedures:
  • Procedures like breast reduction, breast augmentation, gynaecomastia treatment, otoplasty, and blepharoplasty.
• Unregistered Medication:
  • Medication not registered with the Medicine Control Council.
• Unregistered Institutions/Nursing Homes:
  • Services from unregistered institutions or nursing homes (excluding state facilities).
• Specific Dental Items:
  • Items like gum guards and gold used in dentures.
• Frail Care Services:
  • Costs for frail care services.
• Travel Expenses (Except Emergency):
  • Travel expenses, except for Emergency rescue and International cover.
• Non-Medically Necessary Costs:
  • Costs deemed not medically necessary or appropriate by the Medical Assessor.
• Missed Appointments:
  • Costs for missed appointments.
• Circumcision (Unless Clinically Indicated):
  • Circumcision, unless clinically indicated.
• Contraceptive Measures/Devices:
  • Contraceptive measures or devices.
• Reversal of Sterilization:
  • Reversals of vasectomies or tubal ligations (sterilization).
• Substance Abuse Injuries (Except PMBs):
  • Injuries from substance abuse (except Prescribed Minimum Benefits).
• Infertility Treatments (Limited):
  • Infertility treatments (except PMBs in state facilities, subject to Scheme Rules).
• Deep-Sea/Cave Diving Injuries:
  • Injuries from scuba diving at depths over 40 meters or cave diving.

Additional Exclusions for International Emergency Travel Cover (Custom Option Applies):

• Maternity-Related Care:
  • Care or treatment related to maternity, including emergencies, during pregnancy.
• Oncology Care:
  • Oncology care or treatment.
• Organ Transplants:
  • Treatment or care related to organ transplants.
• Chronic Renal Failure Care:
  • Care associated with chronic renal failure.
• Injuries/Illnesses During Waiting Periods:
  • Injuries, illnesses, or emergencies during a three-month or twelve-month condition-specific waiting period.
• Travel Against Medical Advice:
  • Travel against medical advice, seeking medical attention, or with a terminal condition diagnosed prior to travel.
• Failure to Meet Fit to Fly Criteria:
  • Failure to meet criteria in the fit to fly questionnaire.

Key Takeaways for Custom Option Members:

• The Custom Option is subject to all the general exclusions of the Momentum Medical Scheme.
• The Custom option, like Evolve, Incentive, Extender, and Summit, has extra exclusions regarding international travel.
• International travel has many exclusions, it is important to read the fine print.
• Pre existing conditions must be disclosed.
• Cosmetic procedures are generally excluded.
• Substance abuse related injuries are generally excluded.
• Waiting periods are important.

Momentum Custom Option - Organ Transplant Program Details:

General Information:

• Momentum Medical Scheme offers a specialized transplant program.
• A wellness coach and specialized clinical staff guide members.
• Coverage is available for various aspects of the transplant process, contingent upon pre-authorization.
  • This includes pre-transplant evaluations, surgery, post-operative care, benefits following the transplant, rehabilitation, medications, and tests.

Registration for the Organ Transplant Benefit:

• The transplant coordinator at the transplant unit initiates registration.
• An email with supporting documentation is sent to the Disease Risk Management Department at [e-mail].
• Required information for registration:
  • Comprehensive treatment plan and quotation from the transplant unit/specialist.
  • Motivational letter from the treating physician with relevant ICD-10 codes.
  • Psychosocial assessment by a psychiatrist/psychologist.
  • Copies of supporting tests and results.
  • Breakdown of hospitalization costs for each event.
  • Annual costing estimate for immunosuppressive therapy.
  • Detailed cost estimate for the surgery, broken down by event.

Live Organ Donor Request:

• The scheme does not cover the search for a donor.
• Tests related to the donor are covered once a suitable donor is identified and approved.
• Additional documentation required:
  • Copy of blood group for both donor and recipient.
  • Copy of crossmatch results.
  • Letter from the attending physician attesting to the donor's medical fitness.

Process After Registration Request:

• The Scheme may request additional information (e.g., transplant success rates).
• If criteria are met, registration for organ transplantation benefits is approved.
• If criteria are not met, the application is presented to the Clinical Governance Organ Transplant panel.
• The member and doctor are informed of the outcome.
• After the transplant date is confirmed, the member and doctor must request authorization by calling 0860 11 78 59 and providing the reference number from the acceptance letter.

Immunosuppressive Therapy Benefits:

• Registration for immunosuppressive therapy benefits is required post-transplant.
• The doctor must contact the Chronic department:
  • Call 0860 11 78 59.
  • Email a chronic prescription with ICD-10 codes to [e-mail].
  • Fax it to 031 580 0471.
• Coverage for immunosuppressive therapy related to Prescribed Minimum Benefit transplants is available across all options, with registration and approval through the Designated Services Provider.

How to Renew Organ Transplant Authorization:

• If waiting for a transplant, a new cost estimate must be submitted to the Disease Risk Management department's specialized coach once a donor is found.
• If a transplant has occurred, and chronic medication authorization has expired, a new prescription must be sent to [e-mail] or faxed to 031 580 0471.
• Changes to chronic medication require an updated prescription sent to the same email or fax number.

Important Notes for Custom Option:

• If you have selected Associated hospitals as your in-hospital provider, you are required to utilize an Associated hospital for your care. If you choose a different hospital, a co-payment of 30% will be applied to the hospital bill. You can find a list of these hospitals on the Momentum website, or by contacting Momentum directly.
• If you have chosen Associated as your chronic provider, it is essential to obtain your chronic medication from Medipost, adhering to an entry-level Core formulary. If you procure your medication from sources outside of this formulary, a co-payment will be incurred. If you obtain your chronic medication from a pharmacy other than Medipost, the Momentum Medical Scheme will only reimburse 50% of the formulary price for the medication.
• If you have selected State as your chronic provider, you must utilize State facilities for all post-organ transplant benefits and for obtaining your chronic medication, which includes immunosuppressive therapy.
• Immunosuppressive therapy for transplants that do not fall under the Prescribed Minimum Benefit category is covered under the Extender and Summit Options, contingent upon registration and approval.

Donor Benefits:

• R47,900 is allocated for live donor expenses (including transportation).
• R23,600 is allocated for cadaver donor costs.
• Claims for non-member donors should be sent to [e-mail].

Contact Information:

• Web chat: momentummedicalscheme.co.za
• Email: [e-mail]
• WhatsApp
• Phone: [phone]

Key Takeaways for Custom Option Members:

• The transplant process involves a structured registration and pre-authorization procedure.
• Specific documentation is required for both transplant requests and live donor requests.
• Adherence to designated service providers (Associated or State) is important to avoid co-payments, especially for hospital and chronic medication.
• Immunosuppressive therapy requires registration and ongoing management.
• Donor expenses are covered within specified limits.
• Momentum provides support and guidance throughout the process.

Momentum Custom Option - Medical Rehabilitation Benefit Details:

1. General Information:

• Physical rehabilitation aims to help individuals regain strength, mobility, and independence after illness, injury, surgery, or accidents.
• Rehabilitation can take place at home or in a step-down facility.
• Rehabilitation prepares for easier daily living, especially with permanent disabilities.
• Covered treatments and services:
  • Step-down facilities.
  • Occupational therapy.
  • Speech therapy.
  • Physiotherapy.
  • Wound care.
  • Stoma care.
  • Home nursing.
  • Social workers.
• Disabilities can be physical, cognitive, mental, sensory, emotional, or developmental.
• Physical rehabilitation involves a team of specialists (doctors, nurses, psychologists, physiotherapists, social workers, speech therapists, occupational therapists).

2. Available Benefits (Custom Option Specific):

• R61,000 per family for medical rehabilitation, private nursing, hospice, and step-down facilities.
• Subject to case management.

3. Eligibility:

• Members who experienced a significant life-altering event or injury requiring hospitalization.
• A discharge plan from the treating doctor is essential.
• The plan includes follow-up visits, investigations, medications, medical devices, a rehabilitation plan, and step-down facility/hospice transfer.
• Home environment evaluation for safety and accommodation.
• Case manager monitoring.
• Medical schemes cannot provide unlimited rehabilitation funding.
• Coverage ceases when no further functional benefit is expected or skills are transferred to a caregiver.
• Frail care is excluded.

4. Registration for Treatment in a Step-Down Facility:

• Letter of motivation from the treating doctor with:
  • Diagnosis and ICD-10 code.
  • Current clinical condition.
  • Estimated length of stay (if transferring).
  • Completed assessment from a facility with a valid practice number.
  • Treatment plan with length of stay and tariff codes.
• Treating doctor/hospital case manager emails the letter to [e-mail].
• Case manager evaluation based on clinical protocols and evidence-based medicine.
• Response within 48 hours.
• Appeals sent to [e-mail].

5. Registration for Home Nursing or Hospice:

• Letter of motivation from the treating doctor with:
  • Diagnosis and ICD-10 code.
  • Current clinical condition.
  • Estimated duration of service.
  • Completed assessment from a facility with a valid practice number.
  • Treatment plan/services with tariff codes.
• Response within 48 hours.
• Appeals sent to [e-mail].

6. Registration for Wound Care:

• Letter of motivation from the treating doctor with:
  • Diagnosis and ICD-10 code.
  • Current dated, color photographs of the wound.
  • Estimated wound care dates.
  • Nursing sister's valid practice number.
  • Wound care tariff codes.
  • List of required items and dressings.
• Response within 48 hours.
• Appeals sent to [e-mail].
• Weekly progress reports from treating providers are required.

Key Takeaways for Custom Option Members:

• R61,000 per family is available for medical rehabilitation, private nursing, hospice, and step-down facilities.
• All services are subject to case management.
• Specific documentation is required for registration in step-down facilities, home nursing/hospice, and wound care.
• Treating doctors must provide detailed clinical reports and treatment plans.
• Appeals are possible.
• Weekly progress reports are required for wound care.
• Frail care is Excluded.

Prosthesis – internal (including knee and hip replacements, permanent pacemakers, cochlear implants, etc.) Intraocular lenses: R6 900 per beneficiary per event, maximum 2 events per year Other internal prostheses: R59 000 per beneficiary per event, maximum 2 events per year

Momentum GapCover for Custom Option Members:

1. General Information:

• Momentum GapCover is an insurance product underwritten by Guardrisk Insurance Company Limited.
• It's designed to cover financial shortfalls between what medical practitioners charge and what your medical scheme pays.
• It also covers co-payments and specific out-of-hospital/day clinic procedures.
• It is not a medical scheme and should not replace medical scheme membership.
• You must be a member of the Momentum Medical Scheme to apply for Momentum GapCover.

2. Shortfall Benefits (Maximum R190,000 per person per year):

• Benefit for Shortfalls in Medical Practitioner Costs:
  • Covers the difference between medical practitioner fees and medical scheme reimbursement.
  • Custom Option coverage: 400% of the Momentum Medical Scheme Rate.
  • Also covers specific out-of-hospital/day clinic procedures up to the same limit.
• Allied Professionals:
  • Covers shortfalls for allied professionals following an in-hospital procedure.
  • Limited to three times the Momentum Medical Scheme payment, capped at R2,500 per policy per year.
  • Covered professionals include: Chiropractors, Clinical technologists, Genetic counselors, Myotherapists, Occupational therapists, Orthoptists, Osteopaths, Perfusionists, Physiotherapists, Podiatrists, and Speech pathologists.
• Co-payments:
  • Covers co-payments for hospital admissions, procedures, and day clinic treatments.
  • Does not cover co-payments from voluntarily using non-Designated Service Providers (non-DSPs).
• Co-payments on Oncology Treatment:
  • Covers the 20% co-payment after the medical scheme's oncology limit is exceeded.
• Robotic Procedure Shortfall Benefit:
  • Covers shortfalls for robotic-assisted surgery medical practitioner fees, up to three times the medical scheme reimbursement.
• Robotic Procedure Co-payment Benefit:
  • Covers co-payments for robotic-assisted surgery, up to R12,000 per policy per year.
• Casualty Benefit:
  • Covers emergency room casualty fees due to medical emergencies or accidents.
  • Limited to five visits and R23,000 per policy per calendar year.
  • Three visits can be for dependents aged seven or younger (capped at R4,000 per visit).
• Internal Prosthesis Shortfall Benefit:
  • Covers shortfalls for internal prosthesis costs, up to R35,000 per policy per year.
  • Stents and pacemakers have a sub-limit of R8,000 per claim event.

3. Assist Benefits (Do Not Aggregate to the R190,000 Cap):

• Cancer Assist Benefit:
  • Payouts for first-time diagnoses of stage 2 or higher cancer (R8,000 or R20,000).
  • Additional R15,000 if medical scheme pays over R200,000 for oncology treatment within 12 months.
• Breast Reconstruction Benefit for Non-Affected Breast:
  • R15,000 per policy per year for cosmetic reconstruction after mastectomy.
• Accident Assist Benefit:
  • R55,000 payout for death or permanent disability due to an accident.
• Violent Crime Benefit:
  • Doubles the Accident Assist payout to R110,000 if the accident is due to violent crime.
• Premium Waiver Benefit:
  • R36,000 upfront payment to cover medical scheme and GapCover premiums in case of death or permanent disability of the premium payer.
• Trauma and Bereavement Counseling Benefit:
  • R800 per session, up to R30,000 per policy per year, for trauma counseling after violent crime or traumatic events.
• Baby Bump Benefit:
  • R2,500 upfront payment for pregnancy-related expenses.

4. Premiums:

• Premiums vary by age.

5. Waiting Periods:

• 3-month general waiting period.
• 9-month waiting period for pre-existing conditions.
• 12-month waiting period for cancer, birth, and pregnancy.

6. Claims:

• Shortfall claims are processed automatically.
• Assist benefit claims require a claim form.

7. Out-of-Hospital/Day Clinic Procedures Covered:

• Urology, ENT, Orthopaedic, Radiology, Gastro-intestinal, Gynaecology, Cardiovascular, Ophthalmology, General Surgery, Obstetrics, Oncology, and Renal procedures.

8. What Is Not Covered:

• Many things are not covered, including but not limited to, routine examinations, cosmetic procedures, out of hospital dental, and weight loss procedures. Please see the original document for a full list.
• Non-DSP co-payments.
• any costs relating to a BMI.
• Mental health disorders.

Key Takeaways for Custom Option Members:

• Momentum GapCover helps cover medical expense shortfalls and co-payments.
• The Custom Option has 400% medical practitioner shortfall coverage.
• There are various Assist benefits for specific situations.
• Waiting periods apply.
• Specific out-of-hospital procedures are covered.
• Many exclusions exist, including non-DSP co-payments and cosmetic procedures.
• Gap cover is not a medical aid replacement.

Momentum Custom Option - Chronic Renal Disease Program Details:

1. General Information:

• Chronic renal failure (CKD) is a gradual deterioration of kidney function.
• Symptoms include fatigue, concentration issues, poor appetite, sleep problems, muscle cramps, swelling, puffy eyes, dry skin, and frequent urination.
• Treatment includes medication (blood pressure, cholesterol, anemia), supplements (calcium, vitamin D), diet, dialysis, and kidney transplant.
• Momentum Medical Scheme's program provides specialized care, education, lifestyle support, medication management, dietary guidance, and dialysis/transplant services.

2. Registration:

• Registration is required for those diagnosed with CKD by their physician and meeting diagnostic criteria.
• Healthcare provider sends the chronic renal application form and supporting documents to [e-mail].
• Required documents:
  • Pathology reports.
  • Urea and electrolytes results.
  • Full blood count and iron profile.
  • Chronic prescription with ICD-10 codes (sent to [e-mail]).
• Approved medication is subject to a formulary, and co-payments may apply.

3. Treatment and Benefits:

• Treatment plan covers consultations with doctors and allied health professionals (renal dialysis technicians, dieticians).
• Investigations and assessments are covered.
• Additional benefits may be allocated as needed.
• If you have selected Associated as your chronic provider, you must obtain your chronic prescription from an Associated GP and procure your chronic medication from Medipost. Should you choose to obtain your chronic medication from any pharmacy other than Medipost, please be aware that Momentum Medical Scheme will only reimburse 50% of the formulary price.
• Hospitalization:
  • Pre-authorization is required (Momentum App, web chat, [e-mail], WhatsApp, or 0860 11 78 59).
  • Case manager coordinates hospital stay.
  • If you are on the Custom option, and have elected for state chronic providers, you must use state facilities for renal dialysis. If this is not possible, a letter from the state facility, and a motivation letter from the nephrologist must be submitted to [e-mail].
• Dialysis and Transplant Programme Coach provides support for end-stage renal disease and transplants.
• Dialysis treatment requires annual authorization.
• Treatment plan changes require written motivation to [e-mail].
• Benefits:
  • Chronic renal disease medication coverage (Major Medical Benefit, subject to formularies).
  • Investigations and consultations coverage (Major Medical Benefit).
  • Member engagement and communication.
  • Provider profiling and communication.
  • Easier access to benefits for complications.

4. Glossary and Important Information:

• Designated Service Providers (DSPs): Associated GPs/specialists and state facilities.
• Formulary: List of covered medications.
• ICD-10: International Classification of Diseases code.
• Prescribed Minimum Benefits (PMBs): Mandated benefits.
  • Conditions must qualify.
  • Treatment must align with defined benefits.
  • DSPs must be used.
  • Non-DSP use results in reimbursement at the Momentum Medical Scheme Rate and co-payments (except for involuntary emergency use).
  • If conditions and treatment do not meet PMB criteria, reimbursement is according to the selected benefit option.

Key Takeaways for Custom Option Members:

• Registration is essential for accessing program benefits.
• Medication coverage is subject to a formulary.
• Using Associated chronic providers, requires the use of Medipost pharmacy.
• Using state chronic providers requires the use of state facilities.
• Pre-authorization is required for hospitalization.
• A dedicated coach assists with dialysis and transplants.
• PMB benefits require the use of DSPs.
• Adhereing to the correct channels, and providing the correct documentation is very important.

On the Evolve and Custom Options, members can add the Momentum HealthSaver+ to fund their day-to-day healthcare expenses.

Conclusion

The Custom Option provides flexible, extensive healthcare coverage tailored to your needs. It offers a wide range of hospitalization, chronic, and day-to-day benefits with options to reduce monthly contributions by choosing associated hospitals and providers. Additionally, the Health Platform Benefit and complementary products like Momentum HealthSaver help manage out-of-pocket medical expenses effectively.