Focus on the chronic renal disease programme

 

Below is information about the chronic renal disease programme

Chronic renal failure, often referred to as chronic kidney disease (CKD), is a serious medical condition characterized by the gradual deterioration of kidney function over time. As the kidneys lose their ability to function effectively, they become less capable of filtering waste products and toxins from the bloodstream. This inefficiency leads to the accumulation of harmful substances in the body, which can result in various health issues and an overall decline in well-being.

Interestingly, many individuals may not experience significant symptoms until the disease has progressed to a more advanced stage. However, some common symptoms that may arise include:

• Feeling tired and drained of energy: Many patients report a persistent sense of fatigue that does not improve with rest.
• Trouble concentrating: Cognitive difficulties, such as trouble focusing or remembering things, can occur.
• Poor appetite: A decrease in appetite is common, which may lead to unintended weight loss.
• Trouble sleeping: Insomnia or disrupted sleep patterns can be a frequent complaint.
• Muscle cramping at night: Many individuals experience painful muscle cramps, particularly during the night.
• Swollen feet and ankles: Fluid retention can cause noticeable swelling in the lower extremities.
• Puffiness around your eyes, especially in the morning: This symptom can be particularly distressing and is often linked to fluid retention.
• Dry and itchy skin: Skin issues, such as dryness and itching, can be exacerbated by kidney dysfunction.
• The need to urinate more often, especially at night: Frequent urination, particularly during the night, can disrupt sleep and quality of life.

Upon receiving a diagnosis of chronic renal disease, your healthcare provider will work with you to develop a personalized treatment plan tailored to your specific health profile and the severity of your condition. Treatment options may encompass a variety of approaches, including:

• Blood pressure medication: Managing blood pressure is crucial for kidney health, and specific medications may be prescribed.
• Cholesterol lowering statins: These medications can help reduce cholesterol levels, which is important for overall cardiovascular health.
• Anaemia management: Treatment may involve medications or supplements to address anemia, a common complication of kidney disease.
• Calcium and Vitamin D supplementation: These nutrients are vital for bone health and may be prescribed to prevent related complications.
• Low protein diet: Dietary modifications may be necessary to reduce the workload on the kidneys.
• Dialysis: For those with advanced kidney failure, dialysis may be required to filter waste from the blood.
• Kidney transplantation: In certain cases, a kidney transplant may be considered as a long-term solution.

Momentum Medical Scheme’s chronic renal disease programme is designed to provide members at risk of renal failure, as well as those currently experiencing renal failure or who are benefiting from a transplant, with access to specialized care. This comprehensive programme includes essential components such as education about the disease, lifestyle support, medication management, dietary guidance, and options for both haemodialysis and peritoneal dialysis, as well as kidney transplantation services.

Who needs to register and how? Registration is necessary if you have been diagnosed with chronic renal disease by your treating physician and meet the established diagnostic criteria. To initiate the registration process, ask your healthcare provider to complete the chronic renal application form and send it via email to [e-mail]. Along with the application, please include the following documents:

• Pathology reports
• Urea and electrolytes results
• Full blood count and iron profile
• A chronic prescription that includes ICD-10 codes

The chronic prescription should be emailed to [e-mail].

If you meet the necessary criteria, your chronic condition will be registered. It is important to note that chronic renal failure has a specific list of medications, known as a formulary, that are approved for treating the condition. Once your treatment plan is approved, your healthcare provider will be informed about whether the prescribed medication is included in the formulary, as well as any applicable co-payments that may be required.

Additionally, Momentum Medical Scheme offers a comprehensive treatment plan that encompasses all essential consultations with doctors and allied health professionals, such as renal dialysis technicians and dieticians. Investigations and assessments necessary for managing your condition will also be covered. In certain cases, additional benefits may be allocated as needed.

When you receive your prescription, it is essential to take it to your pharmacist. Afterward, claims can be submitted for the approved condition. 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.

If hospitalization becomes necessary due to your condition, you can easily request pre-authorisation by logging into the Momentum App or using the web chat feature available on momentummedicalscheme.co.za. Alternatively, you can email us at [e-mail], send a WhatsApp message, or call us at 0860 11 78 59. A dedicated case manager will assist in coordinating your hospital stay. If you are enrolled in the Ingwe or Evolve Options, you will be covered for Prescribed Minimum Benefits at State facilities. For those on the Custom, Incentive, or Extender Options who have chosen State as their chronic provider, it is imperative to utilize State facilities for renal dialysis. In cases where chronic dialysis or treatment is unavailable or inaccessible at a State facility, you will need to provide a letter on the State facility’s letterhead along with a motivation letter from your nephrologist, which must be emailed to [e-mail] for review. If this documentation is not available, you will be informed of the outcome and the authorized renal provider at the pre-authorisation stage.

A dedicated Dialysis and Transplant Programme Coach will work closely with you and specialized clinical staff to ensure that you receive high-quality and effective care if you are diagnosed with end-stage renal disease requiring dialysis or transplantation. Dialysis treatment is ongoing, and your healthcare provider can contact our call center annually to obtain an authorization number.

For any changes in your treatment plan, a written motivation from your healthcare provider is required. This can be submitted via email to [e-mail].

Benefits of the chronic renal disease programme include several key aspects:

• Coverage for chronic renal disease medication: Your prescribed medications for chronic renal disease will be covered under the Major Medical Benefit, subject to our formularies. A formulary is a comprehensive list of medications that are covered under your specific medical plan, ensuring that your healthcare provider can prescribe the most appropriate treatment for your condition.
• Investigations and consultations: All necessary investigations and consultations will be paid from the Major Medical Benefit. Each registered chronic renal failure or dialysis patient will receive an annual treatment plan that outlines all required procedures, investigations, and consultations to effectively manage their health.
• Member engagement and communication: We prioritize open communication with our members. We will reach out to you via telephone to encourage adherence to clinical care tailored to your health needs, in collaboration with your treating physician.
• Provider profiling and communication: Our scheme is committed to identifying and connecting you with the most suitable general practitioners and specialists, ensuring you receive the highest quality and most cost-effective care available.
• Easier access to benefits: We aim to simplify access to benefits that assist in managing any complications related to chronic renal disease, making it easier for you to receive the care you need.

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

Glossary of terms

Designated service providers: Momentum Medical Scheme collaborates with a network of designated service providers, including Associated GPs and Specialists, as well as State facilities, to ensure our members receive appropriate diagnoses and treatments for Prescribed Minimum Benefits.

A formulary refers to a list of medications that are covered under your specific medical plan, enabling healthcare providers to prescribe the most suitable treatments for your chronic condition.

ICD-10 is the International Classification of Diseases code used for diagnosing various medical conditions.

Prescribed Minimum Benefits represent a set of essential benefits that all medical schemes in South Africa are required to provide coverage for, as outlined in the Medical Schemes Act 131 of 1998 and its associated regulations. To access these benefits, the following criteria must be met:

• Your medical condition must qualify for coverage and 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. For additional information, please refer to the definition of Designated Service Providers provided earlier.

If you voluntarily opt to use non-designated service providers, the Scheme will reimburse benefits up to the Momentum Medical Scheme Rate, and relevant co-payments will apply. In cases of an emergency medical condition where non-designated service providers are used involuntarily, co-payments will be waived.

If your medical condition and treatment do not meet the criteria for accessing these benefits, reimbursement will be provided according to the benefits outlined in your selected benefit option.