Focus on asthma

What is asthma?

Asthma is a long-term, chronic condition that affects the lungs, leading to inflammation and constriction of the airways. This condition is characterized by episodes of wheezing, which produces a whistling sound during breathing, as well as sensations of tightness in the chest, difficulty in breathing, and persistent coughing. These coughing episodes often occur during the night or in the early morning hours, disrupting sleep and daily activities. Asthma can affect individuals of any age, but it commonly begins in childhood. Those with asthma experience inflamed airways, resulting in swelling and increased sensitivity. This inflammation causes the airways to react strongly to various inhaled irritants and allergens. When the airways react, the surrounding muscles tighten, further narrowing the passages and reducing airflow to the lungs. In addition, the swelling can intensify, leading to even narrower airways. The cells lining the airways may also produce an excess of mucus, a thick, sticky substance that can contribute to airway obstruction.

The signs and symptoms of asthma

• Coughing is a common symptom of asthma, particularly noticeable during the night, while exercising, or even when laughing. This persistent cough can be quite bothersome and may interfere with daily activities.
• Difficulty breathing is another hallmark of asthma, where individuals may feel as though they cannot catch their breath, especially during physical exertion or in response to triggers.
• Chest tightness is often reported by asthma sufferers, creating a sensation of pressure or discomfort in the chest area, which can be alarming and distressing.
• Shortness of breath is frequently experienced, leading to feelings of panic or anxiety, particularly during asthma attacks when airflow is severely restricted.
• Wheezing, characterized by a whistling or squeaky sound in the chest during breathing, especially during exhalation, is a classic indicator of asthma and can be quite alarming for both the individual and those around them.

Possible causes of asthma

• Allergens are a significant trigger for asthma symptoms. Common allergens include dust mites, pet dander, cockroach droppings, mold spores, and pollen from various plants such as trees, grasses, and flowers. Exposure to these substances can provoke an asthma attack in susceptible individuals.
• Irritants present in the environment can also exacerbate asthma symptoms. These include cigarette smoke, air pollution, chemical fumes, and dust found in workplaces. Additionally, certain household products, like air fresheners and hairsprays, can act as irritants that worsen asthma conditions.
• Some medications, including aspirin and other non-steroidal anti-inflammatory drugs, as well as non-selective beta-blockers, may trigger asthma symptoms or exacerbate existing conditions.
• Food and drink containing sulfites can provoke asthma symptoms in some individuals, making it essential to be aware of ingredients in processed foods and beverages.
• Viral infections, particularly those affecting the upper respiratory tract, such as common colds, can lead to increased asthma symptoms and complications.
• Physical activity, especially vigorous exercise, can trigger asthma symptoms in some individuals, leading to exercise-induced bronchoconstriction.

How to register on the chronic program

Once you have received a diagnosis of asthma, it is important to take the next step in managing your condition by enrolling in the Chronic Medicine Management Programme. To do this, please ask your healthcare provider to reach out to our Chronic Medicine Department at 0860 11 78 59. A chronic medicine consultant will work closely with your doctor to coordinate your treatment plan. After confirming that the necessary diagnostic criteria have been met and relevant blood tests have been submitted, your treatment will be authorized. You will be informed whether your prescribed treatment aligns with the Momentum Medical Scheme formulary or if you will incur any co-payments. Once you have received authorization, you can present your prescription to your designated service provider (DSP) to obtain your medication, and the claim can be processed accordingly. A DSP is a healthcare provider, such as a doctor, pharmacist, or hospital, that is preferred by the medical scheme for managing care related to Prescribed Minimum Benefit conditions. If you decide to seek care from a non-designated service provider, you may be subject to additional co-payments. Please note that the authorization typically expires after 12 months. If your medication remains unchanged, your doctor or pharmacist can renew the authorization by contacting us at 0860 11 78 59. This process also applies if there are any changes or additions needed for your authorization. To learn more about your chronic benefits and where to access chronic medications and treatments, click here.

Hospitalization

In the event that you require hospitalization due to complications related to cardiac failure, it is essential to initiate the pre-authorization process. You can easily do this by logging into the Momentum App, using the web chat feature available at momentummedicalscheme.co.za, sending us an email at [e-mail], or reaching out via WhatsApp or phone at 0860 11 78 59. Upon your request for pre-authorization, we will assign a case manager who will follow up on your hospital stay and ensure you receive the necessary care.

Treatment plan

Once you are successfully registered in the program, you will gain access to a comprehensive treatment plan tailored to your needs. This plan may cover a variety of essential services, including diagnostic tests, visits to healthcare providers, and other benefits deemed medically necessary by your physician. Our clinical team will review these services to ensure they are appropriate and aligned with your treatment goals.

Compliance

To effectively manage your asthma, it is crucial to adhere to the following compliance guidelines: First, ensure that you obtain your chronic medication on a monthly basis without interruption. Second, it is vital to take the medication exactly as prescribed, following the recommended dosage and quantity provided by your healthcare provider. Lastly, do not miss any doses of your medication, as this is not only important for maintaining compliance but can also have serious implications for your overall health and well-being. Adhering to your treatment regimen is essential for managing asthma effectively and improving your quality of life.

Please make sure your claims have the appropriate ICD-10 code

For all claims submitted, it is imperative that they include the correct ICD-10 codes (diagnostic codes). This ensures that we can accurately identify and process the claim under the Chronic Benefit, facilitating timely reimbursement and support for your treatment.

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

• The claims are submitted without the relevant ICD-10 codes, which may lead to delays or denials.
• You have exceeded the frequency limits for consultations or tests, which may require additional review.
• The treatment provided is deemed not clinically appropriate, which may necessitate further evaluation.

Contact us

If you have any questions or need assistance, feel free to reach out to us through the web chat feature on momentummedicalscheme.co.za, send us an email at [e-mail], send us a WhatsApp message, or simply call us at 0860 11 78 59. We are here to help you navigate your healthcare needs and provide support.

Glossary of terms

Designated service providers: The Momentum Medical Scheme collaborates with a network of designated service providers, including associated general practitioners (GPs) and specialists, as well as state facilities when appropriate, to ensure that our members receive the necessary diagnosis and treatment for Prescribed Minimum Benefits.

A formulary: This is a comprehensive list of medications that are covered under your specific medical plan. It serves as a guide for doctors to prescribe the appropriate treatments for chronic conditions based on the medications included in the formulary.

ICD-10: This refers to the diagnostic code used to identify specific medical conditions.

Prescribed Minimum Benefits: This is a statutory list of benefits that all medical schemes in South Africa are mandated to cover under the Medical Schemes Act No 131 of 1998. These benefits encompass life-threatening emergency medical conditions, a defined set of 271 diagnoses, and 26 chronic conditions. Coverage is provided in full when you utilize the Scheme’s Designated Service Providers (DSPs). If you opt to use non-designated service providers voluntarily, the Scheme will reimburse up to the Momentum Medical Scheme Rate, and applicable co-payments will be enforced. However, in cases of life-threatening emergencies where non-designated service providers are utilized, this is considered involuntary, and co-payments will be waived.