Skip to main content

Benefits and Coverage offered by the Incentive Option

CX Experts
Updated

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

 

The Incentive Option is designed to offer comprehensive coverage for hospitalization and chronic conditions, with the flexibility to select providers and manage costs effectively. Key features include:

  • No overall annual limit on hospitalization expenses.
  • Freedom to choose between private hospitals or a list of designated Associated hospitals for treatment.
  • Option to manage healthcare costs by utilizing Associated doctors and Medipost courier pharmacy for chronic prescriptions and medications.
  • Potential savings when using State facilities for chronic care.

Overall Day-to-Day limit:

Your overall day-to-day limit for the Incentive Option is determined by the allocation of 10% of your total contributions to a Personal Medical Savings Account, which can be used for routine medical expenses.

Focus on the Day-to-day Benefit

On the Incentive Option, 10% of the total contribution goes to a dedicated Personal Medical Savings Account (Savings) to cover day-to-day healthcare expenses. Credit can be advanced upfront for the remaining months in the year and any unused Savings balance at the end of the year will be carried forward to the following benefit year.

Key Features

Major Medical Benefit

  • Provider Options: Any hospital or Associated hospitals network.
  • Annual Limit: None.
  • Specialists: Associated specialists are fully covered; other specialists are reimbursed up to 200% of the Momentum Medical Scheme Rate.
  • Hospital Accounts: Fully covered at agreed rates with the hospital group.
  • Co-payments: May apply for specialized procedures, treatments, and scans (e.g., R1,920 for day hospitals, R3,840 for acute hospitals).

Chronic and Day-to-day Benefits

  • Chronic Care Providers: Any provider, Associated GPs, or State facilities.
  • Chronic Conditions Covered: 32 conditions, including 26 from the Chronic Disease List (no annual limit), and 6 additional conditions with a limit of R13,100 per family annually.
  • Day-to-day Benefits: A portion of the contribution (10%) is allocated to a Personal Medical Savings Account for everyday medical expenses.

Health Platform Benefit

  • Provider Options: Any or Associated providers.
  • Services Covered: Includes preventative screenings, health check-ups, and wellness programs.
  • Savings Allocation: 10% of your contribution is allocated to a dedicated savings account for day-to-day medical needs.

Benefit Breakdown

Hospitalization and Major Medical Benefits

  • No Annual Limit on hospitalization costs.
  • Specialist Coverage:
    • Associated specialists: Fully covered.
    • Non-Associated specialists: Covered up to 200% of Momentum Medical Scheme Rate.
  • Hospital Accounts: Fully covered based on negotiated rates.
  • Pre-Authorization: Required for certain treatments; failure to obtain will incur a 30% co-payment.

Specialized Procedures and Treatments

  • A wide range of specialized procedures is covered, including:
    • Arthroscopies, joint replacements, and more.
  • Co-payment may apply for certain treatments, such as:
    • Day hospitals: R1,920.
    • Acute hospitals: R3,840.

Chronic Benefit

  • Covers 32 conditions with no annual limit for the 26 conditions from the Chronic Disease List.
  • For the additional 6 conditions, the coverage is limited to R13,100 per family annually.
  • Requires registration in the Chronic Management Programme and Scheme approval.

Day-to-Day Benefits

  • Savings Account: 10% of contributions are allocated to a savings account.
  • Coverage includes:
    • General Practitioners, Specialists, Dentistry, Optical care, and more.
  • Coverage for these services is subject to available Savings.

Hospitalization Benefits

  • No Annual Limit for:
    • High and intensive care, organ transplants (recipient), maternity confinements, and neonatal intensive care.
  • Trauma and Medical Rehabilitation: Covered up to R67,000 per family (combined limit).
  • Emergency Medical Transport: No annual limit for Netcare 911 services within South Africa, and up to R8,000,000 per beneficiary for international emergencies.
  • Organ Transplants: Costs for the recipient are fully covered. For the donor, R27,500 for cadaver and R56,000 for live donor costs.

Mental Health and Addiction Treatment

  • Psychiatric and Psychological Services: Covered up to R48,400 per beneficiary.

Dental Benefits

  • In-hospital Dental Treatment:
    • Coverage for maxillo-facial surgery, general anesthesia for children, and trauma-related dental care.
    • Specialized dental procedures are covered from Savings or HealthSaver (if available).

Medical and Surgical Appliances

  • In-Hospital Appliances: Covered up to R8,400 per family.
  • External Appliances: Covered up to R29,400 per family.

Co-payments

  • MRI/CT scans: Subject to a R2,900 co-payment per scan and pre-authorization.
  • Prostheses: Covered up to specific limits:
    • Cochlear implants: R214,200 per beneficiary (1 event per year).
    • Internal prostheses: Up to R64,000 per beneficiary (2 events per year).

Emergency and Specialized Care

  • Emergency Transport: No limit for local emergency transport by Netcare 911.
  • International Emergency: Up to R8,000,000 per beneficiary per 90-day journey.

Summary of Coverage

  • Major Medical Benefit: No annual limit on hospitalization; associated specialists fully covered.
  • Chronic Care: 32 conditions covered, with no annual limit for 26 conditions.
  • Day-to-day Medical Expenses: Covered up to available savings, with services like GP visits, dentistry, and specialist care.
  • Health Platform Benefits: Focus on preventative care and health management programs.

This structure provides extensive benefits while offering flexibility in managing healthcare costs and ensuring comprehensive coverage for essential medical needs.

 

Preventative Care Benefits

  • Pneumococcal Vaccine

    • Eligibility: Beneficiaries aged 60 and older, and high-risk individuals.

    • Frequency: Once a year.

    • Applicable to: Incentive, Evolve, Custom, Extender, and Summit options.

Early Detection Tests

  • Mammogram

    • Eligibility: Women aged 38 and older.

    • Frequency: Every two years.

    • Applicable to: Incentive, Evolve, Custom, Extender, and Summit options.

  • DEXA Bone Density Scan

    • Eligibility: Beneficiaries aged 50 and older.

    • Frequency: Once every three years.

    • Applicable to: Incentive, Evolve, Custom, Extender, and Summit options.

  • Glaucoma Test

    • Eligibility: Beneficiaries aged 40 to 49 (every two years), and 50 and older (annually).

    • Applicable to: Incentive, Evolve, Custom, Extender, and Summit options.

Maternity Programme

  • Doula Benefit

    • Coverage: Two visits per pregnancy.

    • Applicable to: Incentive, Evolve, Custom, Extender, and Summit options.

  • Antenatal and Postnatal Classes

    • Coverage: Up to R430 per pregnancy.

    • Applicable to: Incentive, Extender, and Summit options.

  • Lactation Specialist Consultation

    • Coverage: Initial online consultation.

    • Applicable to: Incentive option.

    • (Follow-up consultations covered under Extender and Summit options.)

Annual Oncology Benefit Limits

  • Limit: R400,000 per year

  • Co-payment: 20% applies after exceeding the limit

  • Conditions: Benefits are subject to SAOC Tier 1-2 guidelines

Providers for Incentive Option

  • State Chronic: Access to ICON providers and Medipost Pharmacy

  • Associated: Can use any SAOC registered provider and Medipost Pharmacy

  • Any Chronic: Can use any SAOC provider and any pharmacy

Treatment Coverage for Incentive Option

  • Active Treatment: Includes chemotherapy, radiotherapy, and necessary materials (pre-authorization required).

  • Non-Active Treatment: Follow-up care and hormonal therapy are covered post-initial treatment (pre-authorization required).

How to Avoid Co-Payments for Incentive Option

  • Use network providers

  • Request generic medications

  • Ensure claims include the correct ICD-10 codes

Maternity Benefits for the Incentive Option

Antenatal Care

  • Antenatal Visits: Up to 12 visits at a gynecologist, GP, or registered midwife.

  • Urine Dipstick Tests (Tariff code 4188) included at these visits.

  • Scans: Coverage for two pregnancy scans. Members can request their doctor to use tariff codes 3615 and 3617, allowing access to 3D or 4D scans at the rate of a 2D scan.

Pathology Tests Covered

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)

  • Antiglobin (3709)

  • Platelet count (3797)

  • Rubella antibody (3948)

Two of each test per pregnancy:

  • Glucose strip (4050)

  • Hemoglobin estimation (3762)

Twelve tests per pregnancy:

  • Urinalysis (4188)

Urine tests covered if requested by a treating doctor:

  • Microscopic exams (3867)

  • Antibiotic susceptibility (3887)

  • Culture (3893)

Postpartum Benefits

  • Nurse Home Visits:

    • One visit on the day after returning home from the hospital after childbirth.

    • Second visit two weeks later.

    • Third visit at six weeks postpartum.

  • Baby Immunizations: Administered at home by a Momentum Wellness nurse up to six weeks old, in line with the Department of Health schedule.

  • Designer Nappy Bag: Comes with essential items for both mother and baby.

  • Family Meal Voucher: Delivered on the first night home, helping parents settle in.

Maternity Coaching & High-Risk Support

  • Access to maternity coaches (trained midwives) via telephone for pregnancy, childbirth, and newborn care questions.

  • If classified as high-risk, your maternity coach will provide regular check-ins, advice, and support throughout the pregnancy.

Doula Benefit

  • Coverage for two doula visits per pregnancy, provided that:

    • The doula is accredited by DOSA or WOMBS.

    • The gynecologist is an Associated Specialist.

    • The member is planning a natural birth.

  • Pre-authorization is required for this benefit.

Pediatric & Baby Care Benefits

  • Pediatrician Visits: Two visits covered in the baby’s first year.

  • Baby Immunizations: Covered for children up to six years, following the Department of Health schedule.

BellyBabies Benefit (Online Antenatal & Postnatal Support)

Members on the Incentive Option have coverage for:

  • Initial video consultation with a lactation specialist (Tariff code: 88001).

  • Online antenatal and postnatal video classes - 18-month subscription per family (Tariff code: 88420).

  • One follow-up video consultation with a lactation specialist is not covered.

Hello Doctor+ (24/7 Doctor Access)

  • Members can talk to or text a doctor anytime, anywhere, 24/7.

  • Accessible via:

    • Momentum App

    • momentummedicalscheme.co.za

    • Hello Doctor app

    • Contact via WhatsApp: 073 778 4632

    • Call: 087 230 0002

Hospital & Associated Specialists

  • Momentum Medical Scheme has contracts with Associated Specialists, including gynecologists, pediatricians, and anesthetists.

  • These specialists charge Scheme rates, ensuring no out-of-pocket costs for in-hospital specialist care.

Authorization & Registration Requirements

  • Pre-authorization for confinement required within 30 days of the delivery date.

  • If hospital admission date changes, it must be reported within 48 hours.

  • Register your newborn within 30 days of birth to waive the first month’s contribution.

  • Contact Information for Registration:

Doula Benefit – Incentive Option

What is a Doula?

A doula is a trained professional providing non-medical support during childbirth and postpartum. While not involved in medical procedures, doulas assist mothers and their partners by offering:

  • Emotional support – Reassurance, guidance, and advocacy.

  • Physical support – Comfort measures during labor and post-birth.

  • Postpartum care – Assistance with newborn care and maternal well-being.

Criteria for Accessing the Doula Benefit

To qualify for the Doula Benefit under the Incentive Option, members must meet the following conditions:

  1. Gynecologist Approval

    • Your gynecologist must be an Associated Specialist registered with Momentum Medical Scheme.

  2. Natural Birth Plan

    • The birth plan must focus on a natural birth, meaning no planned surgical interventions (e.g., C-sections) or medicalized pain relief.

  3. Doula Accreditation

    • The doula must hold a valid practice number and be accredited by recognized professional bodies such as:

      • DOSA (Doulas of South Africa)

      • WOMBS (Women Offering Mothers Birth Support)

Doula Benefit Overview (Incentive Option)

The Doula Benefit is available to members enrolled in the Incentive Option, along with Evolve, Custom, Extender, and Summit Options. Under this benefit, two consultations are covered:

1. Pre-Delivery Consultation (Antenatal)

  • Benefit: One session with the doula before birth.

  • Value (Incentive Option): R2,400

  • Tariff Code (Recommended for Billing): 966072

2. Post-Delivery Consultation

  • Benefit: One post-birth consultation for support and guidance.

  • Value (Incentive Option): R2,400

  • Tariff Code (Recommended for Billing): 966073

Important Notes

  • The Doula Benefit is only available once you register for the Maternity Management Programme.

  • Registration must occur between 8 and 20 weeks of pregnancy to ensure eligibility for the benefit.

Contact Information for Doula Benefit & Maternity Registration

For further details or to register, members can reach Momentum Medical Scheme via:

 

  • Hospital Admissions: No co-payment (except for specific procedures).
  • In-Hospital Dentistry: R1,750 for maxillo-facial surgery (excluding implants).
  • Extraction of Impacted Wisdom Teeth:
    • Day hospitals: R3,450
    • Other hospitals: R6,500
  • MRI and CT Scans: R2,900 per scan.

Incentive Option - Maternity Program Details:

  • Registration:
    • Registration is possible from the eighth week of pregnancy.
    • Methods: Momentum App, online at momentummedicalscheme.co.za, WhatsApp, or phone (0860 11 78 59).
    • Required information: Email address, healthcare provider details (name, surname, practice number), medical/surgical/obstetric history, and expected delivery date.
    • Partnership with BabyYumYum for pre and post natal support.
  • Benefits Offered in Partnership with Momentum Wellness and BabyYumYum:
    • Access to the MyMomentum BabyYumYum portal for parenting information.
    • One nurse home visit on the day after returning from the hospital.
    • Third nurse visit six weeks after childbirth.
    • Baby vaccinations at home by a Momentum Wellness nurse, up to six weeks after birth, according to the Department of Health schedule.
    • Stylish designer nappy bag with essential items for mother and baby.
    • Voucher for a family meal delivery on the first night home.
  • Antenatal Visits:
    • 12 antenatal visits at a gynecologist, GP, or registered midwife.
    • Includes urine dipstick tests.
  • Scans:
    • 2 pregnancy scans.
    • 3D and 4D scans covered up to the rate of 2D scans.
  • Pathology Tests:
    • Specific routine pathology tests covered once per pregnancy:
      • Antiglobin (Tariff code: 3709)
      • Blood group (Tariff code: 3764)
      • Creatinine (Tariff code: 4032)
      • Full blood count (Tariff code: 3755)
      • Platelet count (Tariff code: 3797)
      • Rhesus factor (Tariff code: 3765)
      • Rubella antibody (Tariff code: 3948)
    • Glucose strip tests (Tariff code: 4050) covered twice per pregnancy.
    • Hemoglobin estimations (Tariff code: 3762) covered twice per pregnancy.
    • Urinalysis (Tariff code: 4188) covered up to 12 tests per pregnancy.
    • Urine tests (microscopic examinations, antibiotic susceptibility, cultures) covered if requested by the treating doctor.
  • Maternity Coaches:
    • Access to maternity coaches for telephonic support.
    • Regular contact for high-risk pregnancies.
  • Doula Benefit:
    • 2 doula visits during pregnancy (DOSA or WOMBS accredited doula, Associated Specialist gynecologist, natural birth).
    • Doula benefit must be authorized as part of maternity benefit registration.
  • Audiology, Circumcision, and Physiotherapy:
    • Not routinely covered under the maternity program.
    • Circumcision for medical reasons may be covered with prior authorization.
  • Baby Immunizations:
    • Covered for children up to six years, according to the Department of Health schedule.
  • Paediatrician Visits:
    • 2 pediatrician visits in the baby's first year.
  • BellyBabies Benefit:
    • Online antenatal and postnatal video classes (18-month subscription - Tariff code: 88420).
    • Initial video consultation with a lactation specialist (Tariff code: 88001).
    • Discount on BellyBabies services.
    • HealthSaver+ funds can be used for BellyBabies services.
  • Hello Doctor+:
    • 24/7 access to doctors via phone, text, or app.
  • Associated Specialists:
    • Access to contracted gynecologists, pediatricians, and anesthetists to avoid rate shortfalls.
  • Authorization for Confinement:
    • Pre-authorization required within 30 days of the expected delivery date.
    • Notification of hospital admission date changes within 48 hours.
  • Adding Baby to Membership:
    • Separate newborn registration form required.
    • First month's contribution waived if registered within 30 days of birth (employer-paid contributions must be approved by employer).

 

Incentive Option - Specialized Scans Details:

  • Coverage:
    • Unlimited coverage for MRI and CT scans.
    • Unlimited coverage for MRCP, whole body radioisotope scans, and PET scans.
  • Co-payment:
    • R2,900 per scan.
  • Co-payment Waivers:
    • Co-payments are waived in cases of emergencies.
    • Co-payments are waived for scans related to cancer treatment for members enrolled in the oncology management program, 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.
    • This pre-authorization is required to ensure a smoother process for both patients and healthcare providers.
       
 

Incentive Option - Specialized Procedures/Treatments Details:

  • General Coverage:
    • Specialized procedures and treatments are covered under the Major Medical Benefit, regardless of whether they are performed in a hospital or out-of-hospital setting.
    • Pre-authorization is mandatory for all procedures and treatments.
  • Anaesthetist Costs:
    • R1,300 per procedure (pre-authorization required).
    • Coverage for anaesthetist costs for other procedures will only apply if deemed clinically appropriate.
  • Co-payments for Specialised Procedures:
    • Some procedures may require a co-payment.
    • For specific details on what procedures require copayments, the full documentation must be consulted.
  • +HealthSaver Product:
    • The +HealthSaver product is mentioned as an optional complementary product, but is not considered a medical scheme benefit.
    • Momentum and Momentum medical scheme are seperate entities.
       
 

Incentive Option - Specialized Procedures/Treatments Details:

  • General Coverage:
    • Specialized procedures and treatments are covered under the Major Medical Benefit, whether performed in a hospital or out-of-hospital setting.
    • Pre-authorization is mandatory for all procedures and treatments.
    • The document does not cover all procedures, and direct contact is advised for specific coverage inquiries.
  • Anaesthetist Costs:
    • R1,230 for procedures like gastroscopies and colonoscopies, provided pre-authorization is obtained.
    • For other medical procedures, anaesthetist costs are covered if deemed clinically appropriate.
  • Co-payments:
    • Some specialized procedures and treatments may result in a co-payment.
    • For specific copayment details, the full linked document must be reviewed.
  • HealthSaver and Momentum Products:
    • HealthSaver is a complementary product, not a medical scheme benefit.
    • Momentum is a separate entity from Momentum Medical Scheme.
    • Membership in Momentum Medical Scheme does not require enrollment in Momentum products.

 

Incentive Option - Africa Benefit Details:

  • Eligibility:
    • Members enrolled in the Incentive Option who are employed in sub-Saharan Africa are eligible for this benefit.
  • Coverage:
    • Covers emergency and elective hospital admissions, day procedures, and medical admissions.
    • Emergency medical evacuation to the nearest suitable medical facility.
    • Costs associated with necessary medical, surgical, hospital, emergency transport, and other treatments administered prior to medical evacuation.
  • Provider Option:
    • It is highly recommended that members on the Incentive Option choose the Any Hospital provider option to avoid a 30% co-payment per event.
    • “Event” is defined as a hospital admission or procedure, including all related claims from service providers.
  • Claims:
    • For elective treatments, members pay providers directly and submit claims for reimbursement to africaclaims@momentumhealth.co.za.
    • Claim refunds are only deposited into South African bank accounts.
    • Elective procedures are reimbursed up to a global event fee, based on the average cost in South Africa.
    • Claims must be submitted within four months of the service date to avoid being classified as stale.
    • For medical emergencies, members contact +27 11 541 1263 for authorization and submit authorized claims to internationaltravel@momentumhealth.co.za.
  • Countries Covered:
    • The benefit covers a wide range of sub-Saharan African countries and islands, as listed in the document.
  • Contact Details:
    • From outside South Africa:
      • Member call center: +27 31 573 4008 or +27 31 573 4000
      • Non-emergency claims: africaclaims@momentumhealth.co.za
      • Medical emergencies: +27 11 541 1263 (reverse call charges accepted)
      • Emergency claim submissions: internationaltravel@momentumhealth.co.za
      • Website: momentummedicalscheme.co.za
  • Pre-authorisation
    • Pre-notification is not a requirement for elective procedures.
    • Authorization must be obtained from the scheme’s provider in the event of an emergency.

 

 

 

 
 
 

 

 

 

 

Related to

Related articles

Comments

0 comments

Article is closed for comments.

Powered by Zendesk