Focus on chronic obstructive pulmonary disease (COPD)

What is COPD?

Chronic Obstructive Pulmonary Disease (COPD) is a serious lung condition that significantly impairs the ability to breathe. This debilitating disease results from long-term damage to the lungs, which accumulates over many years. COPD is classified as a progressive disease, meaning it tends to worsen over time, leading to increasingly severe respiratory symptoms.

The condition encompasses two main disorders: chronic bronchitis and emphysema. In COPD, the airways experience inflammation, and the air sacs, or alveoli, within the lungs sustain damage. This damage causes the airways to narrow, making it increasingly difficult to inhale and exhale air effectively. The primary culprit behind the development of COPD is cigarette smoking, which accounts for the majority of cases.

The signs and symptoms of COPD

The symptoms of COPD can vary among individuals, but some of the most common signs include:

• Wheezing: A whistling or squeaky sound when breathing out, often indicative of narrowed airways.
• Breadthlessness: Experiencing difficulty in breathing, whether at rest or during physical activity.
• Tightness in the chest: A sensation of pressure or constriction in the chest area.
• Coughing: A persistent cough that may produce mucus.
• Increased mucus production: Noticing more mucus or phlegm than usual, which can be bothersome and indicative of lung irritation.

Possible causes of COPD

Several factors can contribute to the development of COPD, with the following being the most significant:

• Smoking: The leading cause of COPD, smoking tobacco products such as cigarettes, cigars, and pipes is the primary risk factor. Inhalation of smoke directly damages lung tissue and airways.
• Second-hand smoke: Even non-smokers can develop COPD by being exposed to the smoke from others who smoke. Living with a smoker significantly increases the risk of developing this disease.
• Pollution and fumes: Exposure to air pollution, industrial fumes, and toxic substances can lead to lung damage over time. This includes inhaling dust and chemicals in the workplace, which can contribute to the onset of COPD.
• Asthma: While it is less common, untreated asthma can result in long-term damage to the lungs, potentially leading to COPD. Chronic inflammation from asthma can gradually impair lung function if not properly managed.

How to register on the chronic programme

If you have been diagnosed with COPD, it is essential to initiate your treatment plan by asking your doctor to reach out to our Chronic Medicine Department at 0860 11 78 59 for your registration on the Chronic Medicine Management Programme.

Upon registration, a chronic medicine consultant will collaborate with your healthcare provider to establish an appropriate treatment plan. After the necessary diagnostic criteria are met and relevant blood results are submitted, your treatment will be reviewed and approved. You will be informed whether the prescribed treatment is included in the Momentum Medical Scheme formulary or if you will be required to make a co-payment.

Once you receive authorization for your treatment, you can present your prescription to your designated service provider to obtain your medication, and the claim can then be submitted. A designated service provider (DSP) refers to a preferred healthcare provider, such as a doctor, pharmacist, or hospital, that the medical scheme recommends for members requiring diagnosis, treatment, or care for a Prescribed Minimum Benefit condition. Should you choose to consult a non-designated service provider, you may be subject to a co-payment.

It is important to note that the authorization typically remains valid for 12 months. If your medication remains unchanged, your doctor or pharmacist can contact us at 0860 11 78 59 to renew the authorization. The same process applies if there are any modifications or additions to your treatment plan.

For further information regarding your chronic benefits and where to obtain chronic medication and treatment, click here.

Hospitalization

If you require hospitalization due to complications related to cardiac failure, you can easily request pre-authorization by logging into the Momentum App, using the web chat feature available at momentummedicalscheme.co.za, sending an email to [e-mail], sending us a WhatsApp message, or calling 0860 11 78 59. Upon your request, we will assign a case manager to monitor your hospital stay and ensure appropriate care.

Treatment plan

Once you are successfully registered on the Chronic Medicine Management Programme, you will gain access to a comprehensive treatment plan. This plan may encompass coverage for essential tests, visits to healthcare professionals, and other medically necessary benefits as determined by your doctor. Our clinical team will review these services to ensure their appropriateness and necessity for your health.

Compliance

To effectively manage your condition, it is crucial that you adhere to the following compliance measures:

• Ensure you obtain your chronic medication on a monthly basis without fail.
• Take your medication strictly according to the dosage and quantity prescribed by your healthcare provider.
• Be diligent about not missing doses, as this is vital not only for maintaining compliance but also for safeguarding your overall health and well-being.

Please ensure your claims have the appropriate ICD-10 code

It is imperative that all claims submitted include the correct ICD-10 codes, which are diagnostic codes that allow us to accurately identify and process your claim from the Chronic Benefit.

We may pay claims from your Day-to-day Benefits if:

• The claims are submitted without the necessary ICD-10 codes.
• You have exceeded the allowable frequency limit for consultations or tests.
• The treatment provided is deemed not clinically appropriate.

Contact us

If you have any questions or require assistance, feel free to reach out to us via the web chat feature on momentummedicalscheme.co.za, email us at [e-mail], send a WhatsApp message, or call us at 0860 11 78 59.

Glossary of terms

Designated service providers refer to a network of preferred healthcare providers utilized by the Momentum Medical Scheme, including associated general practitioners (GPs) and specialists, as well as state facilities, depending on specific circumstances. These providers are responsible for diagnosing and treating members for conditions classified under the Prescribed Minimum Benefits.

A formulary is a comprehensive list of medications that are covered under your specific medical scheme option, from which your doctor can prescribe the suitable medication for managing your chronic condition.

ICD-10 refers to the International Classification of Diseases, 10th Revision, which is the coding system used for diagnosing medical conditions.

Prescribed Minimum Benefits encompass a range of essential benefits that all medical schemes in South Africa are mandated to provide coverage for, in accordance with the Medical Schemes Act 131 of 1998 and its associated regulations. To qualify for these benefits:

• Your medical condition must be eligible and listed among the defined Prescribed Minimum Benefit conditions.
• The required treatment must align with the treatments outlined in the defined benefits.
• You must utilize the Scheme’s Designated Service Providers for your care. Refer to the definition of Designated Service Providers for more details.

If you choose to use non-designated service providers voluntarily, the Scheme will cover benefits up to the Momentum Medical Scheme Rate, and applicable co-payments will be enforced. However, if non-designated service providers are utilized in the event of an emergency medical condition, such instances are considered involuntary, and any co-payments will be waived.

If your medical condition and treatment do not meet the aforementioned criteria for accessing these benefits, we will process your claims according to the benefits associated with your selected medical scheme option.