Benefits and cover offered by the Evolve option 2025

The Evolve Option provides cover for hospitalisation at the Evolve Network of private hospitals. There is no overall annual limit for hospitalisation. There is a standard Evolve Option co-payment for all Major Medical Benefits including non-emergency Prescribed Minimum Benefits, except in the case of motor vehicle accidents, maternity confinements or emergency treatment.

You need to use State facilities for all your chronic treatment, including doctors, scripts and medication.

You have cover for two virtual GP consultations from the GP Virtual Consultation Network, which includes Hello Doctor+ . The Health Platform provides cover for a range of day-to-day benefits, such as preventative screening tests, certain check-ups and more. If you need cover for more day-to-day expenses, like additional GP visits or prescribed medicine, you can make use of Momentum HealthSaver+ . HealthSaver is a complementary product offered by Momentum that lets you save for medical expenses not covered on your option.

Core Benefits:

Major Medical Benefit

This benefit includes cover for hospitalisation and certain specialised procedures/treatment. There is no overall annual limit on hospitalisation. Claims are paid up to 100% of the Momentum Medical Scheme Rate. Under the hospitalisation benefit, hospital accounts and related costs incurred in hospital (from admission to discharge) are covered – provided that treatment has been authorised. Specialised procedures/treatment 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.

A co-payment of R1 920 per authorisation applies to Major Medical Benefits including for nonemergency Prescribed Minimum Benefits, except for motor vehicle accidents, maternity confinements, emergency treatment and when you involuntarily use a non-designated Service Provider. An additional co-payment may apply for certain specialised procedures.

If pre-authorisation is not obtained, a 30% co-payment will apply on all accounts related to the event and the Scheme would be responsible for 70% of the negotiated tariff, provided authorisation would have been granted according to the Rules of the Scheme. In the case of an emergency, you or someone in your family or a friend must obtain authorisation within 72 hours of admission. Some procedures are only covered in day hospitals, such as cataract surgery and some sinus procedures

Provider

• Designated hospitals: Evolve Network hospitals.

• Day Hospitals: Some procedures are covered only in day hospitals.

Cover & Limits

• Overall Annual Limit: No overall annual limit applies.

• Rate: Associated specialists are covered in full. Other specialists covered up to 100% of the Momentum Medical Scheme Rate. Hospital accounts are covered in full at the rate agreed upon with the hospital group. 

• Specialised procedures/treatment: Certain procedures/treatment covered
• Co-payments: R1 920 per authorisation, except for motor vehicle accidents, maternity confinements, emergency treatment and when you involuntarily use a nonDesignated Service Provider. An additional co-payment of R3 840 may apply for certain specialised procedures/treatments procedures/treatment co-payment of R3 840 per authorisation applies if performed in an acute or day hospital. 
• Arthroscopies, Back and neck surgery*, Carpal tunnel release, Functional nasal and sinus procedures, Joint replacements*, Laparoscopies: Performed in a day hospital or acute hospital, subject to the relevant co-payment listed above
• Gastroscopies, Colonoscopies, Cystoscopies, Sigmoidoscopies, Nail surgery, Removing of extensive skin lesions: Performed out of hospital, in a day hospital or in an acute hospital, subject to the relevant co-payment listed above
• Conservative back and neck treatment*, Removal of minor skin lesions, Treatment of diseases of the conjunctiva, Treatment of headache, Treatment of adult influenza, Treatment of adult respiratory tract infections: Low severity cases are not covered by the Scheme but can be paid from Momentum HealthSaver, if available High severity cases in an acute hospital are paid by the Scheme, subject to the relevant co-payment listed above
  * Covered at State facilities

Hospitalisation

• Benefit: Associated specialists are covered in full. Other specialists are covered up to 100% of the Momentum Medical Scheme Rate. Hospital accounts are covered in full at the rate agreed upon with the hospital group
• High and intensive care: No annual limit applies
• Casualty or after-hour visits: Subject to Momentum HealthSaver, if available
• Renal dialysis: Limited to Prescribed Minimum Benefits at State facilities
• Oncology: R200 000 per beneficiary per year, thereafter a 20% co-payment applies. Momentum Medical Scheme Reference Pricing applies to chemotherapy and adjuvant medication. You need to get your oncology treatment and medication from the Evolve Network of Oncologists. 
• Organ transplants: Limited to Prescribed Minimum Benefits at State facilities
• In-hospital dental and oral benefits: Not covered. Maxillo-facial trauma covered at State facilities, limited to Prescribed Minimum Benefits
• Maternity confinements: No annual limit applies
• Neonatal intensive care: No annual limit applies
• Medical and surgical appliances in hospital (such as support stockings, knee and back braces, etc): R7 530 per family
• Prosthesis – internal (incl. permanent pacemakers, cochlear implants, etc). Joint replacements, including knee and hip surgery, are limited to Prescribed Minimum Benefits at State facilities: Intraocular lenses: R6 300 per beneficiary per event, maximum 2 events per year Other internal prosthesis: R42 000 per beneficiary per event, maximum 2 events per year
• Prosthesis – external (such as artificial arms or legs, etc): R27 000 per family
• MRI and CT scans, magnetic resonance cholangiopancreatography (MRCP), whole body radioisotope and PET scans (in- and out of hospital): No annual limit applies, subject to co-payment of R3 200 per scan
• Mental health: 
• - - incl. psychiatry and psychology
• - - drug and alcohol rehabilitation
  • Limited to Prescribed Minimum Benefits at Evolve Network hospitals
• Take-home medicine:  7 days’ supply
• Trauma benefit: Covers certain day-to-day benefits that form part of the recovery following specific traumatic events, such as near drowning, poisoning, severe allergic reaction and external and internal head injuries. Appropriate treatment related to the event is covered as per authorisation
• Medical rehabilitation, private nursing, Hospice and step-down facilities: R58 000 per family (combined limit), subject to case management
• Health management programmes for conditions such as mental health, HIV/Aids and oncology: Your doctor needs to register you on the appropriate health management programme
• Immune deficiency related to HIV Anti-retroviral treatment: No annual limit applies at preferred provider
• HIV related hospital admissions R48 300 per family at Evolve Network hospitals
• Emergency medical transport in South Africa by Netcare 911: No annual limit applies
• International emergency medical transport by preferred provider: R5 000 000 per beneficiary per 90-day journey. This benefit includes R15 500 for emergency optometry, R15 500 for emergency dentistry and R765 000 terrorism cover. A R2 180 co-payment applies per emergency out-patient claim

Procedures covered in day hospitals only

• Anorectal: Treatment of haemorrhoids, fissure, fistula. Covered for complicated cases that cannot be treated as an out-patient or where the out-patient treatment options failed and treatment is required in a medical facility
• Biopsies: Skin, subcutaneous tissue, soft tissue, muscle, bone, lymph, eye, mouth, throat, breast, cervix, vulva, prostate, penis, testes
• Breast: Lumpectomy (fibroadenoma)
• Ear, nose and throat: Tonsillectomy and/or adenoidectomy (children up to 12 years). Simple procedures for nosebleed (extensive cautery). Sinus procedures (ethmoidectomy, sinusotomy and lavage). Scopes (nasal endoscopy, laryngoscopy). Middle ear procedures (myringoplasty, stapedectomy, myringotomy and/or grommets). Cochlear implant
• Eye: Corneal transplant. Cataract surgery. Treatment of glaucoma. Other eye procedures: removal of foreign body, conjunctival surgery (repair laceration, pterygium), glaucoma surgery, probing and repair of tear ducts, retinal surgery, eyelid surgery, strabismus repair
• Ganglionectomy
• Gastrointestinal Gastrointestinal scopes (oesophagoscopy, gastroscopy, colonoscopy, sigmoidoscopy, proctoscopy, anoscopy)
• Gynaecological Cerclage of uterine cervix. D&C (dilatation and curettage). Endometrial ablation. Hysteroscopy. Sterilisation. Laparoscopic gynaecological procedures (aspiration ovarian cyst, salpingectomy, fulguration/ablation/lysis of lesions)
• Incision and drainage: Abscess and/or cyst: skin (deep, non-superficial lesions), subcutaneous tissue and pilonidal
• Orthopaedic: Arthroscopy, arthrotomy (shoulder, elbow, knee, ankle, hand, wrist, foot, temporomandibular joint), arthrodesis (hand, wrist, foot). Minor joint procedures (intercarpal, carpometacarpal and metacarpophalangeal, interphalangeal joint arthroplasty). Tendon and/or ligament repair, muscle debridement, fascia procedures (tenotomy, tenodesis, tenolysis, repair/reconstruction, capsulotomy, capsulectomy, synovectomy, excision tendon sheath lesion, fasciotomy, fasciectomy). Subject to individual case review. Repair bunion or toe deformity. Treatment of simple closed fractures and/or dislocations, removal of pins and plates Subject to individual case review.
• Removal of foreign body: Subcutaneous tissue, muscle, external auditory canal under general anaesthesia
• Simple superficial lymphadenectomy
• Skin: Debridement, removal of lesions (dependent on size and diameter), simple repair of superficial wounds Focus on the Evolve Option 2025 Page 10 of 10 Procedures covered in day hospitals only (continued)
• Urological: Cystoscopy, Removal of ureteral stones, Male genital procedures (circumcision for medical reasons only and when authorised, vasectomy)

Chronic and Day-to-Day Benefits

The Chronic Benefit covers certain life-threatening conditions that need ongoing treatment. On the Evolve Option, chronic benefits are available from State facilities only. Chronic cover is provided for 26 conditions according to the Chronic Disease List, which forms part of the Prescribed Minimum Benefits. Chronic benefits are subject to registration and approval by the Scheme.

• Chronic provider and formulary State facilities and State formulary
• Chronic conditions covered: 26 conditions covered according to the Chronic Disease List in the Prescribed Minimum Benefits

Day-to-Day Benefits

You have cover for two virtual consultations from the GP Virtual Consultation Network, which includes Hello Doctor. If you need cover for other day-to-day expenses, like GP visits or prescribed medicine, you can choose to make use of Momentum HealthSaver. HealthSaver is a complementary product offered by Momentum that lets you save for medical expenses not covered by your option.

• Day-to-day provider: Any provider
• Day-to-day benefit: 2 virtual consultations from the GP Virtual Consultation Network, which includes Hello Doctor. 2 physiotherapist or biokineticist consultations per beneficiary for sports injuries, up to R1 120 per year. You can add HealthSaver to provide cover for your day-to-day healthcare expenses, such as additional GP visits and prescribed medicine

General rule applicable to the Day-to-day Benefit: Benefits are subject to Momentum HealthSaver, if available. 

• Acupuncture, Homeopathy, Naturopathy, Herbology, Audiology, Occupational and Speech therapy, Chiropractors, Dieticians, Biokinetics, Orthoptists, Osteopathy, Audiometry, Chiropody, Physiotherapy and Podiatry: Subject to HealthSaver if available
• Mental health (incl. psychiatry and psychology): Subject to HealthSaver if available
• Dentistry – basic (such as extractions or fillings): Subject to HealthSaver if available
• Dentistry – specialised: Subject to HealthSaver if available
• External medical and surgical appliances (incl. hearing aids, glucometers, blood pressure monitors, wheelchairs etc): Subject to HealthSaver if available
• General practitioners 2 virtual consultations from the GP Virtual Consultation Network, which includes Hello Doctor. Consultations include scripting of medication where required. Medication will be subject to Momentum HealthSaver, if available
• Sports injury benefit 2 physiotherapist or biokineticist visits per beneficiary per year for treatment related to sports injuries. Covered at 100% of the Momentum Medical Scheme Rate, up to a maximum of R1 120 per beneficiary per year, subject to pre-authorisation
• Specialists: Subject to HealthSaver if available
• Optical and optometry (incl. contact lenses and refractive eye surgery: Subject to HealthSaver if available
• Pathology (such as blood sugar or cholesterol tests): Subject to HealthSaver if available
• Radiology (such as X-rays): Subject to HealthSaver if available
• MRI and CT scans, magnetic resonance cholangiopancreatography (MRCP), whole body radioisotope and PET scans: Covered from Major Medical Benefit, subject to R3 200 co-payment per scan and pre-authorisation
• Prescribed medication Subject to HealthSaver if available
• Over-the-counter medication: Subject to HealthSaver if available

Preventative Care and Health Platform Benefit :

Health Platform Benefits are paid by the Scheme up to a maximum rand amount per benefit, provided you notify us before using certain benefits. This unique benefit encourages health awareness, enhances the quality of life and gives peace of mind through:

• preventative care and early detection;
• maternity programme; and
• health education and advice.

General rule applicable to the Health Platform Benefit: Health Platform benefits are paid by the Scheme up to a maximum Rand amount per benefit. You do not need to pre-notify before using Health Platform Benefits, except for preventative dental care, pap smears, general physical examinations and HIV tests. Where pre-notification is required, you can pre-notify quickly and easily on the Momentum App, via the web chat facility or by logging on to momentummedicalscheme.co.za. You may also send us a WhatsApp or call us on 0860 11 78 59.

• Benefit:
  • Baby immunisations:
  • Who is eligible?
    • Children up to age 6
  • How often?
    • As required by the Department of Health
• Benefit:
  • Flu vaccines: 
  • Who is eligible?
    • Children between 6 months and 5 years Beneficiaries 60 years and older High-risk beneficiaries
  • How often?
    • Once a year
• Benefit:
  • Tetanus diphtheria injection:
  • Who is eligible?
    • All beneficiaries
  • How often?
    • As needed
• Benefit:
  • Preventative dental care:
    
    • Covered up to R380 per beneficiary at any dental provider.
  • Who is eligible?
    • All beneficiaries
  • How often?
    • Once a year
• Benefit:
  • Pap smear consultation (nurse or GP):
  • Who is eligible?
    • Women 15 and older
  • How often?
    • Once a year
• Benefit:
  • Pap smear (pathologist): 
    
    • Standard or LBC (Liquid based cytology) 
  • Who is eligible?
    • Women 15 and older 
  • How often?
    • Once a year 
• Benefit:
  • Pap smear (pathologist): 
    
    • HPV PCR screening test (If result indicates high risk, then a follow-up LBC is also covered)
  • Who is eligible?
    • Women 21 to 65
  • How often?
    • Once every 3 years
• Benefit:
  • GP Visits 
    
    • General physical examination (GP consultation)
  • Who is eligible?
    • Beneficiaries 21 to 29
  • How often?
    • Once every 5 years
• Benefit:
  • GP Visits 
    
    • General physical examination (GP consultation)
  • Who is eligible?
    • Beneficiaries 30 to 59
  • How often?
    • Once every 3 years
• Benefit:
  • GP Visits 
    
    • General physical examination (GP consultation)
  • Who is eligible?
    • Beneficiaries 60 to 69
  • How often?
    • Once every 2 years
• Benefit:
  • GP Visits 
    
    • General physical examination (GP consultation)
  • Who is eligible?
    • Beneficiaries 70 and older
  • How often?
    • Once a year
• Benefit:
  • Prostate Exam 
    
    • Prostate specific antigen (pathologist)
  • Who is eligible?
    • Men 40 to 49
  • How often?
    • Once every 5 years
• Benefit:
  • Prostate Exam 
    
    • Prostate specific antigen (pathologist)
  • Who is eligible?
    • Men 50 to 59
  • How often?
    • Once every 3 years
• Benefit:
  • Prostate Exam 
    
    • Prostate specific antigen (pathologist)
  • Who is eligible?
    • Men 60 to 69
  • How often?
    • Once every 2 years
• Benefit:
  • Prostate Exam 
    
    • Prostate specific antigen (pathologist)
  • Who is eligible?
    • Men 70 and older
  • How often?
    • Once a year
• Benefit:
  • Health assessment
    
    • Blood pressure test, cholesterol and blood sugar tests (finger prick tests), height, weight and waist circumference measurements.
  • Who is eligible?
    • All principal members and adult beneficiaries
  • How often?
    • Once a year
• Benefit:
  • Cholesterol test (pathologist)
    
    • Only covered if health assessment results indicate a total cholesterol of 6 mmol/L and above. 
  • Who is eligible?
    • All principal members and adult beneficiaries
  • How often?
    • Once a year
• Benefit:
  • Blood sugar test (pathologist)
    
    • Only covered if health assessment results indicate blood sugar levels of 11 mmol/L and above
  • Who is eligible?
    • All principal members and adult beneficiaries
  • How often?
    • Once a year
• Benefit:
  • HIV test 
    
    • HIV test (pathologist)
  • Who is eligible?
    • Beneficiaries 15 and older
  • How often?
    • Once every 5 years

Subject to registration on the Maternity programme between 8 and 20 weeks of pregnancy. 

• Benefit:
  • Doula benefit
    • 2 visits per pregnancy
  • Antenatal visits
    
    • Midwives, GP or gynaecologist
  • Who is eligible?
    • Women registered on the programme
  • How often?
    • 12 visits
  • Benefit:
    • Nurse home visit
    • Who is eligible?
      • Women registered on the programme
    • How often?
      • 2 visits, the day after returning from hospital following childbirth and 2 weeks later
  • Benefit:
    • Urine tests (dipstick)
    • Who is eligible?
      • Women registered on the programme
    • How often?
      • Included in antenatal visits
  • Benefit:
    • Pathology tests
      • Blood group, full blood count, haemoglobin estimation and Rhesus factor
    • Who is eligible?
      • Women registered on the programme
    • How often?
      • 1 test
  • Benefit:
    • Pathology tests
      • Urinalysis
    • Who is eligible?
      • Women registered on the programme
    • How often?
      • 12 tests
  • Benefit:
    • Pathology tests
      • Urine tests (microscopic exams, antibiotic susceptibility and culture)
    • Who is eligible?
      • Women registered on the programme
    • How often?
      • As indicated
  • Benefit:
    • Scans
    • Who is eligible?
      • Women registered on the programme
    • How often?
      • 2 pregnancy scans. We cover 3D and 4D growth scans up to the rate that we pay for 2D scans.
  • Benefit:
    • Paediatrician visits
    • Who is eligible?
      • Babies up to 12 months registered on the programme
    • How often?
      • 2 visits in baby’s first year
  • Benefit:
    • Health line
      • 24-hour emergency health advice
    • Who is eligible?
      • All beneficiaries
    • How often?
      • As needed

Maternity programme on the Evolve Option:

Momentum Medical Scheme’s comprehensive maternity programme is aimed at providing members with the support and quality care they need during their pregnancy and after delivery. The focused, quality care benefits include antenatal visits, scans, nurse home visits, paediatric visits and baby immunisations.

How to register

You can register from the eighth week of your pregnancy

• via the Momentum App;
• by logging on to momentummedicalscheme.co.za; or
• by sending us a WhatsApp message or calling us on 0860 11 78 59. When you register, we need you to provide us with the following information:
• Your email address;
• Your GP, gynaecologist, registered midwife or doula’s name, surname and practice number;
• Your medical and surgical history (including obstetric history); and
• Your expected date of delivery.

Understanding the maternity programme and benefits

Momentum Medical Scheme has partnered with BabyYumYum, South Africa’s leading parenting portal, to provide comprehensive pre- and post-natal support to parents of newborns on Momentum Medical Scheme. When you contact us to register for the maternity benefit, we will ask you to give consent to be a part of the MyMomentum BabyYumYum programme. BabyYumYum will send you a welcome message with details on how to make the most of your benefits. The maternity programme provides the following benefits, depending on your benefit option:

Benefits offered in partnership with Momentum Wellness and BabyYumYum

• Access to current and credible information on all topics relating to parenthood via the exclusive and personalised MyMomentum BabyYumYum portal.
• Support from a Momentum Wellness midwife at home to assist with bathing, swaddling, latching and feeding your baby. Members on all options have access to one nurse home visit on the day after returning home from hospital after childbirth.
• If you are on the Evolve Option, you have an additional visit two weeks later.
• Baby vaccinations at home, administered by a Momentum Wellness nurse, up to six weeks, as per the Department of Health schedule, depending on your benefit option.

Maternity coaches

You have telephonic access to midwifery trained maternity coaches who are able to answer questions about your pregnancy, confinement, postnatal and newborn baby issues. If you have a high-risk pregnancy, your maternity coach will contact you on a regular basis to offer advice, support and encouragement.

Doula benefit

On the Evolve Options, you have two doula visits per pregnancy, provided:

• you make use of a DOSA or WOMBS accredited doula;
• your gynaecologist is an Associated Specialist; and
• you are planning to have a natural birth.

You need to authorise the doula benefit as part of your maternity benefit registration.

Audiology, circumcision and physiotherapy:

Audiology, circumcision and physiotherapy are not routinely covered from Major Medical Benefits, even if performed in hospital. These services would be payable from your Day-to-day benefits or HealthSaver+ , if available. Circumcision for medical reasons would be covered when pre-authorised.

Baby immunisations:

Baby immunisations, in accordance with the Department of Health schedule, are covered for children up to the age of six years. 

Paediatrician visits:

On the Ingwe Options, you have cover for one paediatrician visit in your baby’s first year. On the Evolve Option, you have cover for two paediatrician visits in your baby’s first year.

BellyBabies benefit:

BellyBabies is an exciting offering which provides expecting parents with expert antenatal and postnatal support. BellyBabies offers access to an online antenatal course with 50 educational videos that you can watch at home, as well as video consultations with a lactation specialist to help you and your baby establish and maintain a happy breastfeeding routine.

You can access these benefits by logging on to bellybabies.co.za. Momentum Medical Scheme members receive a discount from BellyBabies. If you have a HealthSaver+ account, you can use available funds to pay for the service.

Authorisation for your confinement:

Please email us at [e-mail], send us a WhatsApp message or call us on 0860 11 78 59 to obtain pre-authorisation for your confinement within 30 days of your delivery date. If your hospital admission date changes, you need to advise us within 48 hours of being admitted.

Adding your baby to your Momentum Medical Scheme membership

We do not automatically add your baby to your Momentum Medical Scheme membership. If you would like your baby to be covered on the Scheme and have access to benefits, such as baby immunisations and paediatrician visits, you need to complete a newborn registration form. The remainder of the first month’s contribution will be free for your baby if you register him or her within 30 days of birth, and the application form must be approved by your employer if your Momentum Medical Scheme contributions are paid by your employer.

Mental health benefits for the Evolve Option 

Mental health disorders comprise a broad range of diagnoses, with different symptoms. However, they are generally characterised by some combination of abnormal thoughts, emotions, behaviour, and relationships with others. Examples of mental disorders are schizophrenia, depression and disorders due to substance abuse. Most of these disorders can be successfully treated.

Bipolar affective disorder and schizophrenia are mental health conditions which are classified as part of the 26 Chronic Disease List Prescribed Minimum Benefit conditions and will therefore be covered in accordance with your chosen chronic provider. Medication is covered as part of the 26 Chronic Disease List conditions.

Depression, drug and alcohol rehabilitation, and acute stress disorder, accompanied by recent significant trauma, are mental health conditions which are classified as part of the 271 Prescribed Minimum Benefit conditions. Medication for these conditions is not covered. Benefits to treat these conditions are either 21 days in-hospital treatment or 15 outpatient consultations. These conditions will be covered at network providers in accordance with your chosen hospital provider, subject to the overall annual limit, where applicable. For outpatient benefits, members are encouraged to use Associated specialists to avoid having to pay for shortfalls when using non-Associated specialists who may charge above the Momentum Medical Scheme Rate.

General rules regarding the mental health benefit

• Benefits are available at Designated Service Providers in accordance with your benefit option.
• Pre-authorisation is required for in and out-of-hospital benefits.
• A treatment plan from your treating doctor will be required.
• Scholastic/educational assessments, disability assessments, forensic investigations and marriage counselling do not form part of the mental health benefit.

Bipolar affective disorder: Forms part of the 26 Chronic Disease List Prescribed Minimum Benefit (PMB) conditions

• Medication: Benefits are available through applicable chronic network providers.

• Doctors, Pathology, and Radiology: Limited to PMBs 

2.Schizophrenia: Forms part of the 26 Chronic Disease List Prescribed Minimum Benefit (PMB) conditions

• Medication: Benefits are available through applicable chronic network providers.

• Doctors, Pathology, and Radiology: Limited to PMBs

Depression, acute stress disorder accompanied by recent significant trauma, alcohol and drug rehabilitation: Form part of the 271 Prescribed Minimum Benefits (PMBs)

• Medication: No benefit
• In-Hospital:Limited to PMBs at Evolve Network hospitals
• Out-of-hospital: Limited to PMBs

Who is eligible for mental health benefits?

If you have been diagnosed with a mental health condition by your family doctor, specialist psychiatrist or psychologist, you will be eligible for the mental health benefits.

How to register

1. Obtain a treatment plan from your treating doctor and/or facility.

2. For hospitalisation, you need to request pre-authorisation. You can do this by emailing us at [e-mail], sending us a WhatsApp message or calling us on 0860 11 78 59 and providing the following details in the letter of motivation from your treating doctor:

• The diagnosis and ICD-10 code;
• The current clinical condition;
• The estimated length of stay if you are being admitted to a facility;
• The completed assessment or DSM form (diagnostic assessment and treatment plan report);
• The treatment plan, including the duration of the treatment with tariff codes to be charged by all healthcare providers, such as psychologists, psychiatrists, etc; Requests for children under the age of 14 must be accompanied by a referral letter from the child’s GP, paediatrician or psychiatrist.

3. Submit a motivation for psychiatric evaluation from your treating doctor for in-hospital benefits for depression, drug and alcohol rehabilitation, and acute stress disorder to us, via email at [e-mail]. Your treating doctor will subsequently also need to send us the psychiatric event first and second reports.

4. For out-of-hospital psychotherapy sessions (for Prescribed Minimum Benefit conditions) instead of hospitalisation, submit an application for outpatient mental health treatment from the treating psychiatrist or psychologist to us via email at [e-mail].

5. Registration for mental health chronic benefits (for bipolar affective disorder and schizophrenia) must be done by the treating psychiatrist via the chronic registration process. The contact number for chronic medication registration is 0860 11 78 59. Once authorised, you need to obtain your chronic medication monthly and make sure that you take your medication according to the dosage and quantity prescribed by your doctor. Make sure that you do not miss a dose, not only from a compliance perspective, but more importantly because it can have serious implications for your health and wellbeing.

Evolve Option - Trauma Benefit (2025):

The Trauma Benefit covers certain day-to-day care and treatment following a hospital admission for specific traumatic events. This benefit is available on the Evolve, Incentive, Extender and Summit Options and appropriate treatment related to the event is covered, subject to authorisation.

Which conditions resulting from a traumatic event are covered?

• Severe burns, subject to specific qualifying criteria, such as the severity of the burns and FIMS* score.
• Paraplegia and quadriplegia, subject to FIMS* score.
• Post-traumatic stress resulting from serious reported crime (subject to qualifying criteria, including a case number for the police report). The following conditions are covered if an ICU stay of five or more days has occurred:
• Conditions resulting from near drowning;
• Poisoning;
• Severe allergic reaction; and
• External and internal head injuries.

How do members access the Trauma Benefit?

Following the admission for the traumatic event, which would need to be pre-authorised in line with emergencies, the treating doctor will need to contact the Scheme to obtain authorisation for the follow up day-to-day care related to the traumatic event. A treatment plan, detailing the treatment required, should be provided to assist with authorisation of the trauma benefits, such as wound care for burns, nursing services, GP and specialist visits, radiology and pathology.

You are welcome to contact us via the web chat facility on momentummedicalscheme.co.za, email us at [e-mail], send us a WhatsApp message on [phone] or call us on 0860 11 78 59 for more information or assistance.

* FIMS: The Functional Independent Measure Scale, which is a measure of the ability to participate in daily living activities.

Evolve Option - International Emergency Travel Cover (2025):

• Eligibility:
  • Beneficiaries enrolled in the Evolve Option are covered for international leisure trips lasting up to 90 days.
• Coverage Limits (per beneficiary):
  • R5 million
• Additional Coverage:
  • Emergency Optometry: Up to R15,500
  • Emergency Dental Care: Up to R15,500
  • Terrorism-Related Incidents: Up to R765,000
  • Out-Patient Co-payment: R2,180 per claim
• Definitions:
  • Medical Expenses: Reasonable and customary charges for treatments needed due to an emergency while traveling internationally. Includes hospital stays, surgeries, and prescribed treatments.
  • Optical Expenses: Emergency optical treatments up to R15,500, provided by a registered optometrist or ophthalmic surgeon.
  • Dental Expenses: Emergency dental treatments up to R15,500, provided by a registered dentist.
• What Constitutes an Emergency Condition?
  • A sudden and unexpected illness or injury during an insured journey requiring immediate medical or surgical treatment to prevent serious health consequences.
• Coverage Period:
  • Start: Coverage begins when you leave South Africa.
  • End: Coverage lasts for 90 consecutive days or until your return to South Africa, whichever comes first.
• Pre-Notification Requirements:
  • Mandatory pre-notification before traveling internationally to activate the benefit.
  • Fit-to-Travel Confirmation: Required from your South African doctor if:
    • You’ve been hospitalized in the past two months.
    • You have certain health conditions (e.g., diabetes, hypertension, cardiovascular issues).
    • You are over 70 years old, pregnant, or have specific chronic conditions (e.g., respiratory diseases).
  • Exclusions: Active oncology treatment, chronic renal dialysis, and certain maternity-related treatments will not be covered, even with a fit-to-travel confirmation.
• Pre-Notification Process:
  • How to Pre-Notify:
    • Momentum App
    • Web Chat: momentummedicalscheme.co.za
    • Email: [e-mail]
    • WhatsApp
    • Phone: Call 0860 11 78 59
  • Required Information:
    • Membership Number
    • ID/Passport Numbers for all travelers
    • Travel Dates (departure and return)
    • Countries Visited and travel purpose
  • Travel Certificate:
    • Upon pre-notification, you will receive a Travel Certificate and embassy letter (if traveling to Schengen countries for visa purposes). The certificate can also be downloaded from the Momentum App.
• Consequences of Not Pre-Notifying:
  • Failure to pre-notify before leaving South Africa will result in loss of coverage.
• What to Do in Case of Emergency Treatment Abroad:
  • Call the Scheme’s Emergency Helpline: [phone] (reverse charges accepted)
  • Pre-Authorization: Obtain pre-authorization for treatment.
  • Treatment Coordination: The helpline will arrange necessary emergency transport and directly settle medical expenses with service providers.
  • Reimbursement: For expenses paid upfront, submit claims with documentation and authorization details to [e-mail]. Include the R2,180 co-payment for each out-patient claim.
  • Note: Claims will not be covered if the emergency assistance helpline is not contacted for authorization.
• Co-Payments:
  • In-Hospital Treatment: No co-payment required.
  • Out-Patient Emergency: R2,180 co-payment per claim.
    • Pay upfront and submit a claim for reimbursement upon returning to South Africa.
    • Claims are subject to your Day-to-Day Benefits and may be reimbursed after deducting the co-payment.
• General Exclusions:
  • Momentum Medical Scheme will not cover expenses arising from:
    • Pre-existing conditions not disclosed during membership application.
    • Costs exceeding the annual maximum limits outlined in the Scheme Rules.
    • Injuries or conditions resulting from:
      • Participation in riots, civil commotion, war, terrorism, or rebellion.
      • Professional speed contests or trials.
    • Treatments not medically necessary, including cosmetic procedures, obesity-related expenses, and infertility treatments.
    • Costs associated with scuba diving beyond 40 meters, cave diving, and other extreme sports.
    • Maternity care or oncology treatments while traveling.
    • Organ transplant-related expenses.
    • Any treatment if you were traveling against medical advice or for a terminal condition.
• For more information or assistance:
  • Contact Momentum Medical Scheme via the Momentum App, email, or call the provided contact numbers.

Evolve Option - Momentum Hello Doctor (2025):

• Free Medical Advice: 24/7 Access:
  • Eligibility: Momentum Medical Scheme members can access free medical advice 24/7.
  • Accessible via the Momentum App.
  • How it works:
    • Tap the Hello Doctor icon on your home screen.
    • Request a phone call from a qualified doctor.
    • The doctor will call you, and there are no charges or service fees involved.
    • Use either mobile data or WiFi connection.
    • The doctor calls you, so you won't use your airtime.
• Virtual Telehealth Consultations:
  • Paid Service:
    • Cost: R278 per consultation.
    • Provides more comprehensive medical assistance, including diagnosis and treatment.
    • Doctors can electronically prescribe certain scheduled medications.
    • Prescriptions for acute medications can be sent directly to your pharmacy of choice.
  • Free Consultations for Members:
    • Evolve Option: Two free virtual consultations per year.
  • Payment Options:
    • Pay using funds from your HealthSaver+ or medical savings account.
    • Alternatively, pay via credit or debit card (payments processed through the Momentum App).
• Scheme Rules and Usage Guidelines:
  • Important Considerations:
    • Adhere to Scheme Rules, including using Designated Service Providers as specified by your Momentum Medical Scheme option.
    • The Hello Doctor service is discretionary, and in-person consultations should be sought if you experience adverse symptoms or medical emergencies.
• Additional Momentum Products:
  • Momentum Group Products:
    • Members can explore additional products offered by Momentum Group Limited and its subsidiaries, including Momentum Multiply.
  • Separation from Medical Scheme Benefits:
    • Momentum is not a medical scheme and operates separately from the Momentum Medical Scheme.
    • Momentum products are not included in the medical scheme benefits, and you can be a member of the Momentum Medical Scheme without enrolling in any Momentum products.

Key Takeaways for Evolve Option Members:

• Evolve option members have 24/7 access to free medical advice via the Momentum App.
• Evolve Option members get two free virtual telehealth consultations per year.
• Additional telehealth consultations are available at a cost of R278.
• Payments for paid consultations can be made via HealthSaver+, medical savings, or credit/debit card.
• The Hello Doctor service is not a replacement for in person medical care in the case of emergencies.
• Momentum products are seperate from the medical scheme.

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Evolve Option - HIV/Aids Management Programme Details:

• General Information:
  • Momentum Medical Scheme provides comprehensive management and treatment for individuals with HIV/Aids.
  • Goal: Ensure access to suitable medical care, promoting wellness, prevention, and support.
  • Members must enroll in the Lifesense HIV programme to access benefits.
• Who Needs to Register:
  • Any member with a positive HIV test result must enroll promptly.
  • HIV Elisa test is covered under the Health Platform Benefit (Ingwe Option: Ingwe Primary Care Network providers only).
  • Pregnant members must register immediately upon learning their HIV status.
• How to Register:
  • Registration is confidential.
  • Member or treating physician contacts Lifesense.
  • Lifesense collaborates with healthcare providers to develop a treatment plan.
  • Includes ongoing education, support, and access to antiretroviral (ARV) medication.
  • Scheme manages annual benefit limits.
• Benefits for Post-Exposure Prophylaxis (PEP) Treatment:
  • PEP treatment is available for potential HIV exposure (accidental or sexual assault).
  • Contact Lifesense to access PEP treatment.
• Where to Get Anti-Retroviral Medication:
  • For Evolve Option members, anti-retroviral medication can be obtained through Medipost.
• Lifesense Contact Details:
  • Tel: [phone]
  • Fax: [phone]

Key Takeaways for Evolve Option Members:

• Enrollment in the Lifesense HIV programme is mandatory for accessing benefits.
• Prompt registration is crucial after a positive HIV test.
• Medipost is the designated provider for ARV medication.
• Lifesense provides comprehensive support and treatment management.
• Post exposure prophylaxis is available.

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Evolve Option - Dental Benefits Details:

• Preventative dental care: Covered up to R380 per beneficiary at dentists, dental therapists and oral hygienists
• Basic dentistry, such as extractions or fillings: Payable from HealthSaver+ if available
• Specialised dentistry, such as bridges or crowns: Payable from HealthSaver+ if available
• In-hospital dental and oral benefits: Not covered. Dentistry related to trauma is covered at State facilities, limited to Prescribed Minimum Benefits

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Evolve Option - Organ Transplant Programme Details:

• General Information:
  • Momentum Medical Scheme has a specialized transplant program.
  • Wellness coach and clinical staff provide support.
  • Coverage for pre-transplant evaluations, surgery, post-operative care, rehabilitation, medications, and tests (pre-authorization required).
• How to Register:
  • Transplant coordinator at the transplant unit initiates registration.
  • Email request and documentation to [e-mail].
  • Required documentation:
    • Treatment plan and quotation.
    • Physician's motivational letter with ICD-10 codes.
    • Psychosocial assessment.
    • Supporting tests and results.
    • Hospitalization cost breakdown.
    • Annual immunosuppressive therapy cost estimate.
    • Detailed surgery cost estimate.
  • Live organ donor request additional documents:
    • Donor and recipient blood group copies.
    • Crossmatch results copy.
    • Attending physician's letter attesting to donor's medical fitness.
  • Scheme may request additional information.
  • Registration if criteria are met; Clinical Governance Organ Transplant panel review if not.
  • Authorization required after transplant date is confirmed (call 0860 11 78 59 with reference number).
• Immunosuppressive Therapy Benefits:
  • Doctor contacts the Chronic department to register:
    • Call 0860 11 78 59
    • Email chronic prescription with ICD-10 codes to [e-mail]
    • Fax to 031 580 0471.
  • Coverage for Prescribed Minimum Benefit transplants in all options, with registration and approval through Designated Service Providers.
• How to Renew Organ Transplant Authorization:
  • If waiting for a transplant: new cost estimate to the Disease Risk Management department's specialized coach.
  • If post-transplant and chronic medication authorization expired: new prescription via email to [e-mail] or fax to 031 580 0471.
  • Updated prescription for any chronic medication changes.
• Important Notes:
  • For the Evolve Option:
    • Organ transplant benefits, including immunosuppressive therapy, are subject to Prescribed Minimum Benefits.
    • Must be accessed through State facilities.
• Contact Us:
  • Web chat: momentummedicalscheme.co.za
  • Email: [e-mail]
  • WhatsApp
  • Phone: [phone]

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Evolve Option - Medical Rehabilitation Benefit Details:

• General Information:
  • Physical rehabilitation assists in regaining strength, mobility, and independence after illness, injury, surgery, or accidents.
  • Rehabilitation can occur at home or in step-down facilities.
  • Covers step-down facilities, occupational therapy, speech therapy, physiotherapy, wound care, stoma care, home nursing, and social workers.
• Available Benefits:
  • Evolve Option: Families can receive up to R58,000 for medical rehabilitation, private nursing, hospice, and step-down facilities, all subject to case management.
• Eligibility:
  • Eligibility for medical rehabilitation benefits is generally extended to members who have experienced a significant life-altering event or injury that typically requires hospitalization for treatment.
  • A discharge plan from the treating doctor is required.
  • Home environment evaluation may be required.
  • Case manager from Momentum Medical Scheme will monitor recovery.
  • Frail care is excluded.
• How to Register for Treatment in a Step-Down Facility:
  • Letter of motivation from the treating doctor, including:
    • Diagnosis and ICD-10 code.
    • Current clinical condition.
    • Estimated length of stay (if applicable).
    • Completed assessment from a facility with a valid practice number.
    • Treatment plan with requested length of stay and tariff codes.
  • Email to [e-mail].
  • Response within 48 hours.
  • Appeals sent to [e-mail].
• How to Register for Home Nursing or Hospice:
  • Letter of motivation from the treating doctor, including:
    • Diagnosis and ICD-10 code.
    • Current clinical condition.
    • Estimated duration of service.
    • Completed assessment from a facility with a valid practice number.
    • Treatment plan and tariff codes.
  • Response within 48 hours.
  • Appeals sent to [e-mail].
• How to Register for Wound Care:
  • Letter of motivation from the treating doctor, including:
    • Diagnosis and ICD-10 code.
    • Current dated, color photographs of the wound.
    • Estimated dates for wound care.
    • Valid practice number of the nursing sister.
    • Tariff codes.
    • List of required items and dressings.
  • Response within 48 hours.
  • Appeals sent to [e-mail].
  • Weekly progress reports required.

Key Takeaways for Evolve Option Members:

• The Evolve Option provides up to R55,000 for medical rehabilitation services.
• Registration requires detailed letters of motivation from treating doctors.
• Specific information is needed for step-down facilities, home nursing/hospice, and wound care.
• Case management is utilized.
• Frail care is excluded.
• Weekly progress reports are required for wound care.

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Evolve Option - Momentum GapCover+ Details:

• Medical Practitioner Shortfall:
  • The Evolve option members will have coverage up to 400% of the Momentum Medical Scheme Rate. This means if your medical scheme pays a certain amount, the GapCover can cover up to four times that amount for the shortfall.
• General Shortfall Benefits:
  • Like all other options, the Evolve option has a maximum shortfall benefit of R190,000 per insured person per year.
• Allied Professionals:
  • The Evolve option is included in the benefit that covers the financial shortfall between fees charged by allied professionals and the amount reimbursed by the Momentum Medical Scheme for in-hospital care. This coverage is limited to three times the amount paid by the Momentum Medical Scheme, capped at R2,500 per policy per year.
• Co-payments:
  • The Evolve option benefits from coverage for co-payments applied by the medical scheme for hospital admissions, procedures, and certain day clinic treatments. This benefit does not cover co-payments incurred due to the voluntary use of non-Designated Service Providers.
• Oncology Co-payments:
  • The Evolve option is included in the benefit that covers the 20% co-payment applied to oncology treatment once the medical scheme limit has been exceeded.
• Robotic Procedure Shortfall Benefit:
  • If a member of the Evolve option requires robotic assisted surgery, the gap cover will cover the shortfalls relating to the medical practitioners fees.
• Robotic Procedure Co-payment Benefit:
  • If a member of the evolve option requires robotic assisted surgery, and their medical aid implements a co-payment, then the gap cover will cover up to R12 000 per year.
• Casualty Benefit:
  • Members of the Evolve option have access to the casualty benefit, which covers emergency room admissions at registered hospital casualty facilities. This coverage is limited to five casualty visits and up to R23,000 per policy per calendar year. There is also the sub benefit where up to 3 of the casualty visits may be used for dependents 7 years old and younger. The emergency benefit is capped at R4,000 per casualty event.
• Internal Prosthesis Shortfall Benefit:
  • The Evolve option is included in the benefit that covers shortfalls associated with internal prosthesis costs, up to a maximum of R35,000 per policy per year. Specific sub-limits apply, such as R8,000 per claim event for stents and pacemakers, subject to the overall policy limit.
• Assist Benefits:
  • Evolve option members have access to the assist benefits, which do not aggregate to the R190,000 cap. These include:
    • Cancer Assist benefit.
    • Breast reconstruction benefit.
    • Accident Assist benefit.
    • Violent crime benefit.
    • Premium waiver benefit.
    • Trauma and bereavement counselling benefit.
    • Baby bump benefit.
• Eligibility:
  • To qualify for Momentum GapCover+, Evolve option members must also be members of the Momentum Medical Scheme

• • You will be informed about formulary coverage and potential co-payments.
  • Once authorized, you can obtain medication from a Designated Service Provider (DSP).
  • If you use a non-DSP, you may incur a co-payment.
  • Authorization typically expires after 12 months, and renewal is possible by contacting 0860 11 78 59.
  •  
• Hospitalization:
  • If hospitalization is required due to RA complications, pre-authorization is necessary.
  • You can request pre-authorization via the Momentum App, web chat (momentummedicalscheme.co.za), email ([e-mail]), WhatsApp, or phone [phone]).
  • A case manager will monitor your hospital stay.
• Treatment Plan:
  • Upon registration, you gain access to a treatment plan covering necessary tests, doctor consultations, and other medically essential benefits.
  • The clinical team will review the treatment plan for appropriateness.
• Compliance:
  • Adherence to the prescribed medication regimen is crucial.
  • Ensure monthly medication collection and proper dosage.
  • Avoid missed doses.
  • Claims must include the correct ICD-10 codes.
  • Claims lacking ICD-10 codes, exceeding frequency limits, or deemed clinically inappropriate may be processed from Day-to-Day Benefits.
• Designated Service Providers (DSPs):
  • Momentum Medical Scheme utilizes DSPs (including associated GPs and specialists, and state facilities) for diagnosing and treating Prescribed Minimum Benefit (PMB) conditions.
  • If you voluntarily use non-DSPs, the Scheme will cover benefits up to the Momentum Medical Scheme Rate, and co-payments will apply.
  • Co-payments are waived for involuntary non-DSP use in emergency medical situations.
• Formulary:
  • The formulary is a list of medications covered under the plan. Your doctor will prescribe medications from this list.
• ICD-10:
  • ICD-10 codes are diagnostic codes used to identify medical conditions.
• Prescribed Minimum Benefits (PMBs):
  • PMBs are mandated benefits that all South African medical schemes must cover.
  • Eligibility requires:
    • The condition being on the PMB list.
    • Treatment aligning with PMB guidelines.
    • Use of DSPs

Optical benefits

Optical benefits and optometry benefits (including contact lenses and refractive eye surgery) is subject to Momentum HealthSaver+, if available.

Circumcision, unless clinically indicated, and any contraceptive measures or devices are excluded from the Evolve plan.

Cataract removal surgery is covered from the Major Medical Benefit, irrespective of whether the procedure/treatment is performed in- or out-of-hospital. Pre-authorisation is required, regardless of where the procedure/treatment is performed. 

Acupuncture, Homeopathy, Naturopathy, Herbology, Audiology, Occupational and Speech therapy, Chiropractors, Dieticians, Biokinetics, Orthoptists, Osteopathy, Audiometry, Chiropody, Physiotherapy and Podiatry is all subject to Momentum HealthSaver+, if available.

Specialised dentistry (such as bridges or crowns) is subject to Momentum HealthSaver+, if available.