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Benefits and coverage offered by the Extender option (2025)

CX Experts
Updated

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

 

The Extender Option offers robust coverage for hospital stays, chronic treatment, and day-to-day healthcare expenses. Here’s a breakdown of its key features:

Major Medical Benefit

  • Provider: Choose any hospital or one of the Associated hospitals.
  • Limit: No overall annual limit on hospitalization.
  • Coverage:
  • Associated specialists: Fully covered.
  • Other specialists: Reimbursed up to 200% of the Momentum Medical Scheme Rate.
  • Hospital accounts: Covered in full based on the agreed rate with the hospital group.
  • Co-payments: May apply for specialized procedures, treatments, and scans.
  • Specialized Procedures: Some procedures may require pre-authorization and could be subject to a co-payment.

Overall day-to-day benefits:

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 Extender Option, 25% of the total contribution goes to a dedicated Savings account to cover day-to-day healthcare expenses. Credit can be advanced upfront for the remaining months in the year. Any unused Savings balance at the end of the year will be carried forward to the following benefit year. If this component is not enough to cover annual day-to-day expenses, members will have a self-funding gap to pay out of their own pocket up to the Threshold, which is determined by the family size (see below). Although claims add up to the Threshold at 100% of the Momentum Medical Scheme Rate, members may claim a higher amount from Savings if the provider charges more than the Momentum Medical Scheme Rate. This will result in a bigger self-funding gap. Members can add the Momentum HealthSaver+ , a complementary product available from Momentum, to fund their self-funding gap. The annual Threshold levels for 2025 are: • Principal member: R33 400 • Per adult dependant: R29 000 • Per child dependant: R9 600 (maximum of 3 children) Once the Threshold has been reached, claims will be paid from Extended Cover at the Momentum Medical Scheme Rate, subject to certain sub-limits. These day-to-day limits accumulate before and after the Threshold.

Chronic and Day-to-Day Benefits

Chronic Treatment Coverage

  • Chronic Provider Options:
  • Any provider
  • Associated GPs and Courier pharmacy (Core formulary)
  • State facilities (State formulary)

Conditions Covered:

  • 26 conditions covered under the Chronic Disease List (Prescribed Minimum Benefits) with no annual limit.
  • 36 additional conditions with a limit of R13,100 per family per year.
  • Self-funded Options: Use State facilities for savings or opt for Associated doctors and Medipost pharmacy.

Day-to-Day Coverage

  • Personal Medical Savings: 25% of your contribution covers day-to-day medical expenses.
  • Thresholds (Family Size-Based):
  • Principal member: R33,400
  • Adult dependant: R29,000
  • Child (up to 3 children): R9,600 per child
  •  

Extended Cover: Available once the threshold is met.

Health Platform Benefit

The Health Platform Benefit provides coverage for:

  • Preventative screening tests
  • Check-ups and health-related services
  • Maternity program
  • Health education

Additionally, 25% of your contribution is allocated to a Personal Medical Savings account for daily expenses. If this amount is insufficient, the Extended Cover benefit kicks in once you reach your predetermined Threshold.

Major Medical Benefit Details

  • No Annual Limit on Hospitalization: Associated specialists are fully covered, and other specialists are reimbursed at 200% of the Momentum Medical Scheme Rate.
  • Hospital Accounts: Fully covered based on the hospital group rate.
  • Co-payments: Apply to certain specialized treatments, procedures, and out-of-hospital care.
  • Specialized Treatments: Certain treatments require pre-authorization. Failure to obtain authorization may lead to a 30% co-payment.

Chronic Benefit

  • Chronic Provider: Choose any, associated, or state provider.
  • Conditions Covered:
  • 26 chronic conditions (no limit)
  • 36 additional conditions with R13,100 limit per family per year.
  • Health Management Program: Registration and approval by the Scheme are required.

Day-to-Day Benefit

  • Contribution Allocation: 25% of your contribution is set aside for day-to-day medical expenses.
  • Threshold:
  • Principal member: R33,400
  • Adult: R29,000
  • Child: R9,600
  • Extended Cover: Once the threshold is reached, the Scheme covers remaining claims.

Health Platform Benefit (Continued)

  • Benefit Limit: Coverage is subject to a maximum rand amount per benefit.
  • Notifications: Certain benefits require prior notification for coverage.

Coverage for Specialized Services

  • Renal Dialysis: No limit, but if you choose State as your chronic provider, you must use State facilities.
  • Oncology: Limited to R500,000 per beneficiary per year, with a 20% co-payment after the limit.
  • Organ Transplants: No annual limit for the recipient. For the donor, a limit of R27,500 (cadaver) and R56,000 (live donor) applies.

Hospitalization Coverage

  • In-Hospital Services: Includes emergency treatments, intensive care, and organ transplants.
  • Dental and Oral Benefits: Maxillo-facial surgery, dental treatments, and anesthesia are covered, subject to specific co-payments.
  • Maternity: No annual limit for maternity confinements and neonatal intensive care.
  • MRI/CT Scans: No annual limit, but subject to a R2,900 co-payment per scan.
  • Prostheses:
  • Internal prostheses covered up to R234,000 per beneficiary for cochlear implants.
  • External prostheses (e.g., artificial limbs) are covered up to R30,600 per family.

Emergency Medical Benefits

  • Emergency Transport: Unlimited coverage for emergency medical transport within South Africa by Netcare 911.
  • International Emergency Transport: Covered up to R8,220,000 per beneficiary per 90-day journey, including optometry, dentistry, and terrorism cover.

Chronic Management Program

  • Registration: Required for all chronic conditions.
  • Conditions Covered: 62 conditions, including HIV, oncology, and organ transplants.
  • Additional Coverage: State facilities may be used if needed, and alternative providers are subject to Scheme approval.

This summary provides an overview of the Extender Option's benefits, highlighting flexibility, no annual hospitalization limits, and customizable healthcare options. For more specific details and to understand your personal coverage, please refer to the official Scheme brochure.

Day-to-Day Benefit

General Rule:

  • 25% of your contribution is allocated to cover day-to-day expenses (Savings).
  • If your Savings are insufficient for annual expenses, you will need to self-fund up to a Threshold based on your family size.
  • Once the Threshold is reached, claims are paid from the Extended Cover benefit at the Momentum Medical Scheme Rate, subject to sub-limits.

Annual Threshold Levels:

  • Principal Member: R33,400
  • Adult Dependant: R29,000
  • Child Dependant: R9,600 (up to three children)
  • If you do not enroll in January, your Threshold and sub-limits will be adjusted pro-rata based on remaining months.

Provider Options:

  • You can choose Any or Associated providers.
  • Associated providers are required for chronic care if selected as the provider.

Services Covered Under Day-to-Day Benefits (Unlimited):

  • Alternative therapies: Acupuncture, Homeopathy, Naturopathy, Herbology, Audiology, Occupational Therapy, Speech Therapy, Chiropractors, Dieticians, Biokinetics, Orthoptists, Osteopathy, Chiropody, Podiatry, Physiotherapy
  • Mental Health: R25,200 per family
  • Dentistry:
  • Basic Dentistry (e.g., extractions, fillings): Unlimited
  • Specialized Dentistry (e.g., crowns, bridges): R17,300 per beneficiary, R44,900 per family
  • Dental specialist accounts for impacted wisdom teeth extraction are covered at 100%, subject to R1,750 co-payment and pre-authorization.
  • External Medical and Surgical Appliances: R31,200 per family, with a sub-limit of R9,420 for hearing aids.
  • General Practitioners (GP): Reimbursed at 100% of the Momentum Medical Scheme Rate, depending on your provider choice.
  • Specialists: Reimbursed at 100% of the Momentum Medical Scheme Rate.
  • Optical & Optometry: R5,300 per beneficiary, with a frame sub-limit of R2,890.
  • Pathology (e.g., blood tests): Unlimited
  • Radiology (e.g., x-rays): Unlimited

Other Covered Services:

  • MRI & CT scans, MRCP, PET scans: Covered from the Major Medical Benefit, with a R2,900 co-payment per scan.
  • Prescribed Medication: R22,200 per beneficiary, R42,100 per family.
  • Over-the-Counter Medication: Covered through Savings and not contributing to the Threshold.

Health Platform Benefit

General Rule:

  • Health Platform Benefits are paid by the Scheme up to a maximum amount per benefit.
  • Pre-notification is required for preventative dental care, pap smears, general physical examinations, and HIV tests. Pre-notification can be done via the Momentum App, web chat, or phone.

Preventative Care

Baby Immunizations:

  • Eligibility: Children up to age 6
  • Frequency: As required by the Department of Health

Flu Vaccines:

  • Eligibility: Children (6 months to 5 years), beneficiaries 60+, and high-risk beneficiaries
  • Frequency: Once a year

Tetanus Diphtheria Injection:

  • Eligibility: All beneficiaries
  • Frequency: As needed

Pneumococcal Vaccine:

  • Eligibility: Beneficiaries 60+, and high-risk beneficiaries
  • Frequency: Once a year

Early Detection Tests

Preventative Dental Care:

  • Benefit: R380 per beneficiary at any dental provider
  • Eligibility: All beneficiaries
  • Frequency: Once a year

Pap Smear Consultation:

  • Eligibility: Women aged 15+
  • Frequency: Based on the type of pap smear

Pap Smear (Pathologist):

  • Eligibility: Women aged 15+
  • Frequency: Once a year

HPV PCR Screening Test:

  • Eligibility: Women aged 21-65
  • Frequency: Once every 3 years

Mammogram:

  • Eligibility: Women aged 38+
  • Frequency: Once every 2 years

DEXA Bone Density Scan:

  • Eligibility: Beneficiaries aged 50+
  • Frequency: Once every 3 years

General Physical Examination (GP Consultation):

  • Eligibility:
  • Aged 21-29: once every 5 years
  • Aged 30-59: once every 3 years
  • Aged 60-69: once every 2 years
  • Aged 70+: once a year

Prostate Specific Antigen (Pathologist):

  • Eligibility:
  • Aged 40-49: once every 5 years
  • Aged 50-59: once every 3 years
  • Aged 60-69: once every 2 years
  • Aged 70+: once a year

Health Assessment (e.g., blood pressure, cholesterol, blood sugar tests):

  • Eligibility: All principal members and adult beneficiaries
  • Frequency: Once a year

Cholesterol Test (Pathologist):

  • Eligibility: Principal members and adult beneficiaries
  • Frequency: Once a year (if total cholesterol is ≥ 6 mmol/L)

Blood Sugar Test (Pathologist):

  • Eligibility: Principal members and adult beneficiaries
  • Frequency: Once a year (if blood sugar is ≥ 11 mmol/L)

Glaucoma Test:

  • Eligibility:
  • Aged 40-49: once every 2 years
  • Aged 50+: once a year

HIV Test (Pathologist):

  • Eligibility: Beneficiaries aged 15+
  • Frequency: Once every 5 years

Pregnancy & Maternity Care

Doula Benefit:

  • Eligibility: Women registered on the program
  • Frequency: 2 visits per pregnancy

Antenatal Visits (Midwives, GP, or Gynecologist):

  • Eligibility: Women registered on the program
  • Frequency: 12 visits

Online Antenatal & Postnatal Classes:

  • Eligibility: Women registered on the program
  • Frequency: 18-month subscription

Online Video Consultations with Lactation Specialists:

  • Eligibility: Women registered on the program
  • Frequency: Initial and follow-up consultations

Nurse Home Visits:

  • Eligibility: Women registered on the program
  • Frequency: 3 visits

Urine Tests (Dipstick):

  • Eligibility: Women registered on the program
  • Frequency: Included in antenatal visits

Pathology Tests:

  • Eligibility: Women registered on the program
  • Tests: Antiglobin, blood group, creatinine, full blood count, platelet count, Rhesus factor, Rubella antibody
  • Frequency: 1 test

Pregnancy Scans:

  • Eligibility: Women registered on the program
  • Frequency: 2 scans (3D and 4D scans covered at the rate of 2D scans)

Emergency & General Services

Paediatrician Visits:

  • Eligibility: Babies up to 12 months
  • Frequency: 2 visits in the baby’s first year

24-Hour Emergency Health Advice:

  • Eligibility: All beneficiaries
  • Frequency: As needed

Extender Option Details:

  • Annual Limit:
  • The Extender option provides coverage up to R500,000 per year.
  • A 20% co-payment is applied to costs exceeding this annual limit.
  • Conditions:
  • Benefits are subject to South African Oncology Consortium (SAOC) Tier 1-2 guidelines.
  • Providers:

State Chronic:

  • Care is provided through ICON network providers.
  • Medipost Pharmacy is the designated pharmacy.
  • Use of non-network providers incurs a 20% additional cost.

Associated Chronic:

  • Care is provided through any SAOC registered provider.
  • Medipost Pharmacy is the designated pharmacy.
  • Use of non-network providers incurs a 20% additional cost.

Any Chronic:

  • Care is provided through any SAOC registered provider.
  • Any pharmacy can be used.

Treatment Types:

Active Treatment:

  • Includes chemotherapy, radiotherapy, and necessary materials.
  • Requires pre-authorization.

Non-Active Treatment:

  • Covers follow-up care and hormonal therapy post-initial treatment.
  • Subject to pre-authorization.
  • Exclusions:
  • Treatments outside SAOC/ICON guidelines.
  • Certain medications.
  • Reconstruction surgery.
  • Co-Payment Avoidance:
  • Use network providers.
  • Request generic medications.
  • Ensure correct ICD-10 codes on claims.
  • Pre Authorization:
  • Active treatment, and non active treatment requires pre authorization.
  • Provider network:
  • Depending on the chronic type chosen by the client, the provider network changes.

Extender Option Co-Payment Details:

  • 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.

General Co-Payment Rules That Apply to Extender:

  • Pre-authorization:
  • Must be obtained at least 48 hours before hospital admissions or specialized treatments.
  • Failure to do so results in a 30% co-payment on claims.
  • Emergency situations: Authorization can be obtained within 72 hours.
  • Non-Network Providers:
  • If members use non-network hospitals or providers, a 30% co-payment applies.

Important Notes:

  • Members must always verify their specific option details to confirm which co-payments are applicable.
  • Momentum Medical Scheme members can access additional products offered by Momentum Group, but these are separate from medical scheme benefits.
     

Extender Option - Health Platform Benefits:

Preventative Care Benefits:

  • Baby Immunizations:
  • Coverage across all options, following Department of Health guidelines.
  • Flu Vaccines:
  • Available for children (6 months to 5 years), beneficiaries aged 60 and older, and high-risk individuals.
  • Tetanus Diphtheria Injection:
  • Available as needed.
  • Pneumococcal Vaccine:
  • Eligibility: Beneficiaries aged 60 and older, and high-risk individuals.
  • Frequency: Once a year.

Early Detection Tests:

  • Preventative Dental Care:
    • Coverage: Up to R380 per beneficiary at dentists, dental therapists, or oral hygienists.
    • Frequency: Once a year.
  • Pap Smear Consultation:
    • Eligibility: Women aged 15 and older.
    • Frequency: Once a year.
    • Consultation with a nurse, GP, or gynecologist.
  • Pap Smear (Pathologist):
    • Eligibility: Women aged 15 and older.
    • Frequency: Once a year (standard or liquid-based cytology) or every three years (HPV PCR screening).
  • Mammogram:
    • Eligibility: Women aged 38 and older.
    • Frequency: Every two years.
  • DEXA Bone Density Scan:
    • Eligibility: Beneficiaries aged 50 and older.
    • Frequency: Once every three years.
  • General Physical Examination:
    • Eligibility:
    • Aged 21 to 29: once every five years.
    • Aged 30 to 59: every three years.
    • Aged 60 to 69: every two years.
    • Aged 70 and older: once a year.
  • Prostate Specific Antigen (Pathologist):
    • Eligibility: Men aged 40 and older.
    • Frequency: Based on age.
  • Health Assessment:
    • Coverage: Tests for blood pressure, cholesterol, blood sugar, height, weight, and waist circumference.
    • Frequency: Once a year for principal members and adult beneficiaries.
  • Cholesterol and Blood Sugar Tests (Pathologist):
    • Frequency: Once a year for principal members and adult beneficiaries.
  • Glaucoma Test:
    • Eligibility: Beneficiaries aged 40 to 49 (every two years), and 50 and older (annually).
  • HIV Test (Pathologist):
    • Eligibility: Beneficiaries aged 15 and older.
    • Frequency: Once every five years.

Maternity Programme:

  • Registration:
    • Women must register between 8 to 20 weeks of pregnancy.
  • Key Benefits:
    • Doula Benefit: Two visits per pregnancy.
    • Antenatal Visits: Twelve visits.
    • Antenatal and Postnatal Classes: 18-month online subscription or face-to-face classes. Coverage: Up to R430 per pregnancy.
    • Lactation Specialist Consultation: Follow-up consultations covered.
    • Nurse Home Visit: Available the day after returning from the hospital, with additional visits at specified intervals.
    • Urine Tests (Dipstick): Included in antenatal visits.
    • Pathology Tests: Various tests covered, including antiglobin, platelet count, and rubella antibody tests.
    • Pregnancy Scans: Coverage for up to three-dimensional and four-dimensional scans at the rate of two-dimensional scans.
    • Paediatrician Visits: Two visits.

General Information:

    • Pre-Notification:
    • Preventative dental care, pap smears, general physical examinations, and HIV tests require pre-notification.
    • Pre-notification can be done via the Momentum App, web chat, Momentum website, WhatsApp, or by calling 0860 11 78 59.
    • Health Line:
    • A 24-hour emergency health advice line is available.

Extender Option - Chronic Benefit Details:

Provider:

    • Members can choose from:
    • Any provider.
    • Associated provider.
    • State provider.

Conditions Covered:

    • 62 conditions in total.
    • Includes the 26 conditions listed in the Chronic Disease List (PMB).
    • Includes 36 additional conditions.

Additional Conditions Coverage:

    • There is a limit of R13,100 per family per year for the 36 additional conditions.

Annual Limit:

    • No annual limit on the 26 PMB conditions (subject to the formulary).
    • R13,100 annual limit on the 36 additional conditions.

Chronic Medication Procurement:

    • State Provider:
    • Chronic prescription can be obtained from any GP.
    • Chronic medication can be sourced from any pharmacy (subject to formularies).
    • Any/Associated provider:
    • Chronic medication can be obtained from any pharmacy (subject to formularies)
    • If preferred medication is used, there is no co-payment if it is within the Momentum Reference Price.
    • If non-preferred medication is used, a 5% co-payment applies.
    • If a pharmacy other than Medipost is used, the scheme covers 50% of the formulary price, and the member pays the balance.

Chronic Medication Registration Process:

    • For Any Chronic Provider:
    • The treating doctor or pharmacist contacts Momentum Medical Scheme at 0860 11 78 59.
    • A chronic benefit consultant assesses and approves or declines the request via phone.
    • Relevant tests may be requested from the provider.
    • After approval, medication can be collected from any pharmacy.
    • Renewed prescriptions must be submitted every 6 months.

For Associated Chronic Provider:

    • Associated GP or Medipost pharmacist contacts Momentum Medical Scheme.
    • Chronic benefit consultant assesses and approves or declines the request via phone.
    • Relevant tests may be requested.
    • Prescription is sent to Medipost for delivery.
    • Renewed prescriptions must be submitted every 6 months.
    • For State Chronic Provider:
    • Contact Momentum Medical Scheme at 0860 11 78 59 for an application form.
    • The state doctor completes the form and submits it to Momentum.
    • Medication is collected from the state hospital pharmacy.
    • For changes in medication or conditions, a new application must be submitted after consulting with the state doctor.
  • Formulary:
    • The Extender option uses the Extended Formulary.
    • Preferred products: Momentum Reference Price applies.
    • Non-preferred products: Co-payment applies (5%).
  • Reference Price:
    • The Momentum Medical Scheme Reference Price is the maximum amount reimbursed for a medication. Co-payments may apply if the medication exceeds this price.

Extender Option - Specialized Procedures/Treatments:

    • Anaesthetist Costs:
    • Coverage: R1,300 per procedure (pre-authorization required).
    • Other Procedures: Coverage will only apply if deemed clinically appropriate.
    • Co-payments for Specialised Procedures:
    • Some procedures may require a co-payment.
    • Please refer to the full co-payment documentation for specific co-payment amounts for specific procedures.
    • General Information:
    • All specialized procedures and treatments require pre-authorization.
    • The specialized procedures and treatment are covered under the Major Medical Benefit.
    • Coverage applies whether the procedures are performed in a hospital or out-of-hospital setting.
    • The document does not detail every procedure covered. Members must contact momentum to confirm coverage of specific procedures.

+HealthSaver Product:

    • The +HealthSaver product is available to members of the Momentum Medical Scheme, but is a seperate product offered by Momentum.
    • Momentum is a seperate entity from the Momentum Medical Scheme.
    • Momentum products are not medical scheme benefits.
    • Membership in the Momentum Medical Scheme does not require enrollment in any Momentum products.

Extender Option - Maternity Program Details:

Registration:

    • Registration can begin from the eighth week of pregnancy.
    • Methods:
    • Momentum App
    • momentummedicalscheme.co.za
    • WhatsApp
    • Phone: 0860 11 78 59
  • Required information:
    • Email address
    • Provider details (GP, gynecologist, midwife, doula)
    • Medical and obstetric history
    • Expected delivery date

Benefits:

  • Antenatal Visits:
    • 12 visits at a gynecologist, GP, or midwife, including urine dipstick tests (tariff code 4188).
  • Scans:
    • Coverage for two pregnancy scans.
    • 3D and 4D scans covered up to the rate of 2D scans (tariff codes 3615 and 3617).
  • Pathology Tests:
    • Coverage includes one of each:
    • Antiglobin (3709)
    • Blood group (3764)
    • Creatinine (4032)
    • Full blood count (3755)
    • Platelet count (3797)
    • Rhesus factor (3765)
    • Rubella antibody (3948)
    • Coverage includes two of each:
    • Glucose strip (4050)
    • Hemoglobin estimation (3762)
    • 12 urinalysis tests (4188).
    • Additional urine tests covered if requested by the doctor:
    • Microscopic exams (3867)
    • Antibiotic susceptibility (3887)
    • Culture (3893)
  • Doula Benefit:
    • Two doula visits per pregnancy.
    • Conditions:
    • Doula accredited by DOSA or WOMBS.
    • Gynecologist is an Associated Specialist.
    • Planned natural birth.
    • Doula benefit must be authorized during maternity registration.
  • Baby Immunizations:
    • Coverage for children up to six years, as per the Department of Health schedule.
    • Seperate pre-authorization is needed after birth.
  • Pediatrician Visits:
    • Two pediatrician visits during the baby’s first year.
  • BellyBabies Benefit:
    • Online antenatal and postnatal classes (18-month subscription - 88420).
    • Initial and follow-up video consultations with a lactation specialist (88001 and 88006).
  • Nurse Home Visits:
    • First visit the day after returning from the hospital.
    • Second visit two weeks later.
    • Third visit six weeks after the initial visit.
  • Additional Benefits:
    • A voucher for a family meal delivered on the first night home.
    • A designer baby bag with essentials.
    • Access to the MyMomentum BabyYumYum portal.
  • Hello Doctor+:
    • 24/7 access to doctors via phone or text.

General Information:

    • Registration with BabyYumYum is optional.
    • Audiology, circumcision, and physiotherapy are not routinely covered.
    • Circumcision for medical reasons is covered if pre-authorized.
    • Newborn must be registered seperately to the medical aid to obtain benefits.
    • Pre-authorization for confinement is required within 30 days of the delivery date.
    • Momentum products are seperate from Momentum Medical Scheme benefits.

Contact Information:

    • momentummedicalscheme.co.za (web chat)
    • member@momentumhealth.co.za
    • WhatsApp
    • 0860 11 78 59

Extender Option - Doula Benefit Details:

  • Doula Definition:
    • A doula is a trained professional providing non-medical support during childbirth and postpartum.
    • They offer emotional, physical, and postpartum support.
  • Criteria for Accessing the Doula Benefit:
    • Gynecologist must be an Associated Specialist with Momentum Medical Scheme.
    • The birth plan must focus on a natural birth.
    • The doula must be accredited by DOSA or WOMBS and have a valid practice number.
  • Doula Benefit Overview:
    • Available for members on the Extender option.
  • Pre-Delivery Consultation (Antenatal Consultation):
    • Benefit: One pre-delivery consultation.
    • Value: R2,400.
    • Tariff Code: 966072 (recommended for billing).
    • Post-Delivery Consultation:
    • Benefit: One post-delivery consultation.
    • Value: R2,400.
    • Tariff Code: 966073 (recommended for billing).
  • Important Notes:
    • The Doula Benefit is activated upon registration for the Maternity Management Programme.
    • Registration must occur between the 8th and 20th weeks of pregnancy.
  • Contact Information:
    • Momentum App.
    • Webchat: momentummedicalscheme.co.za.
    • Email: preauthorisation@momentumhealth.co.za.
    • WhatsApp: +27 860 11 78 59.
    • Phone: 0860 11 78 59.
       

Extender Option - Maternity Program Details:

Registration:

    • Registration from the 8th week of pregnancy.
    • Methods:
    • Momentum App
    • momentummedicalscheme.co.za
    • WhatsApp
    • 0860 11 78 59
  • Required Information:
    • Email address
    • Provider details (GP, gynecologist, midwife, doula)
    • Medical and obstetric history
    • Expected delivery date

Benefits:

Antenatal Visits:

    • 12 visits at a gynecologist, GP, or midwife, including urine dipstick tests (tariff code 4188).

Scans:

    • 2 pregnancy scans.
    • 3D and 4D scans covered up to the rate of 2D scans (tariff codes 3615 and 3617).

Pathology Tests:

    • Coverage includes one of each:
    • Antiglobin (3709)
    • Blood group (3764)
    • Creatinine (4032)
    • Full blood count (3755)
    • Platelet count (3797)
    • Rhesus factor (3765)
    • Rubella antibody (3948)
    • Coverage includes two of each:
    • Glucose strip (4050)
    • Hemoglobin estimation (3762)
    • 12 urinalysis tests (4188).
    • Urine tests (microscopic exams, antibiotic susceptibility, cultures) covered if requested by the treating doctor.
  • Doula Benefit:
    • 2 doula visits.
    • Conditions:
    • DOSA or WOMBS accredited doula.
    • Gynecologist is an Associated Specialist.
    • Planned natural birth.
    • Doula benefit authorization during maternity registration.
    • Baby Immunizations:
    • Children up to 6 years, as per the Department of Health schedule.
    • Seperate pre-authorization is required after birth.
    • Pediatrician Visits:
    • 2 visits in the baby's first year.
    • BellyBabies Benefit:
    • Online antenatal and postnatal classes (18-month subscription - 88420).
    • Initial and follow-up video consultations with a lactation specialist (88001 and 88006).
    • Nurse Home Visits:
    • First visit the day after returning from the hospital.
    • Second visit two weeks later.
    • Family meal voucher.
    • Designer baby bag with essentials.
    • Hello Doctor+:
    • 24/7 access to doctors via phone or text.

General Information:

    • Registration with BabyYumYum is optional.
    • Audiology, circumcision, and physiotherapy are not routinely covered.
    • Circumcision for medical reasons is covered if pre-authorized.
    • Newborn registration is separate.
    • Pre-authorization for confinement is required within 30 days of the delivery date.
    • Momentum products are seperate to medical aid benefits.

Contact Information:

    • momentummedicalscheme.co.za (web chat)
    • member@momentumhealth.co.za
    • WhatsApp
    • 0860 11 78 59
       

Extender Option - Africa Benefit Details:

Eligibility:

    • Members enrolled in the Extender option who are employed in sub-Saharan Africa.

Coverage:

    • Emergency and elective hospital admissions.
    • Day procedures.
    • 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:

    • Recommended to choose the "Any Hospital" provider option to avoid a 30% co-payment per event.
    • "Associated Hospital" provider option incurs a 30% co-payment per event.

Pre-Notification/Authorization:

    • Pre-notification is not required for the Africa Benefit.
    • In emergencies, authorization must be obtained from the Scheme’s provider while in sub-Saharan African countries.

Elective Treatment Claims:

    • Members pay providers directly and submit claims for reimbursement to africaclaims@momentumhealth.co.za.
    • Reimbursements are deposited into South African bank accounts only.
    • Reimbursement is up to a global event fee based on the average cost the Scheme would pay in South Africa.
    • Claims must be submitted within four months of the service date to avoid being classified as "stale."

Emergency Treatment Claims:

    • Members do not pay upfront.
    • Contact the Scheme’s provider at +27 11 541 1263 (reverse call charges accepted) for authorization.
    • Submit authorized claims to internationaltravel@momentumhealth.co.za.

Covered Countries:

    • Angola, Benin, Botswana, Burundi, Cameroon, Comoros, DRC, Djibouti, Equatorial Guinea, Eritrea, Ethiopia, Gabon, Ghana, Guinea, Kenya, Lesotho, Liberia, Madagascar, Malawi, Mauritius, Mozambique, Namibia, Nigeria, Réunion, Rwanda, Seychelles, Sierra Leone, Swaziland, Tanzania, Togo, Uganda, Zambia, Zimbabwe.

Contact Details (Outside South Africa):

    • Member call center: +27 31 573 4008 or +27 31 573 4000.
    • Non-emergency claims: africaclaims@momentumhealth.co.za.
    • Medical emergency contact: +27 11 541 1263 (reverse call charges accepted).
    • Emergency claim submissions: internationaltravel@momentumhealth.co.za
    • Website: momentummedicalscheme.co.za.

Key Points:

    • An "event" includes hospital admission or procedure, and all related claims.
    • The Africa Benefit is separate from the Emergency Travel Benefit, which requires pre-notification when leaving South Africa.
    • The Africa benefit is governed by the Scheme Rules and clinical protocols.

Extender Option - Specialized Procedures/Treatments:

Anaesthetist Costs:

    • Coverage: R1,230 per procedure (pre-authorization required) for procedures like gastroscopies and colonoscopies.
    • Other Procedures: Coverage will only apply if deemed clinically appropriate.

Co-payments for Specialised Procedures:

    • Some procedures may require a co-payment.
    • Refer to the provided document for specific co-payment amounts for specific procedures.

General Information:

    • All specialized procedures and treatments require pre-authorization.
    • The specialized procedures and treatment are covered under the Major Medical Benefit.
    • Coverage applies whether the procedures are performed in a hospital or out-of-hospital setting.
    • The document does not detail every procedure covered. Members must contact Momentum to confirm coverage of specific procedures.

HealthSaver Product:

    • The HealthSaver product is available to members of the Momentum Medical Scheme, but is a separate product offered by Momentum.
    • Momentum is a separate entity from the Momentum Medical Scheme.
    • Momentum products are not medical scheme benefits.
    • Membership in the Momentum Medical Scheme does not require enrollment in any Momentum products.

Extender Option - Specialized Scans Details:

Coverage:

    • Unlimited coverage for MRI, 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.
    • Members enrolled in the oncology management program will not need to pay co-payments for scans related to cancer treatment, 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.

2025 Amendments:

    • Momentum Medical Scheme’s benefit and contribution amendments for 2025 have been submitted to the Council for Medical Schemes and are pending approval from the Regulator.

Extender Option - Doula Benefit Details:

    • Doula Definition:
    • A doula is a trained professional providing non-medical support during childbirth and postpartum.  
       
    • They offer emotional, physical, and informational support.  
       
    • Criteria for Accessing the Doula Benefit:
    • Gynecologist must be an Associated Specialist with Momentum Medical Scheme.
    • The birth plan must focus on a natural birth.
    • The doula must be accredited by DOSA or WOMBS and have a valid practice number.
    • Doula Benefit Overview:
    • Available for members on the Extender option.

Pre-Delivery Consultation (Antenatal Consultation):

    • Benefit: One pre-delivery consultation.
    • Value: R2,280.
    • Tariff Code: 966072 (recommended for billing).

Post-Delivery Consultation:

    • Benefit: One post-delivery consultation.
    • Value: R2,280.
    • Tariff Code: 966073 (recommended for billing).
    • Important Notes:
    • The Doula Benefit is activated upon registration for the Maternity Management Programme.
    • Registration must occur between the 8th and 20th weeks of pregnancy.
    • Contact Information:
    • Momentum App.
    • Webchat: momentummedicalscheme.co.za.  
       
    • Email: preauthorisation@momentumhealth.co.za.
    • WhatsApp: +27 860 11 78 59.
    • Phone: 0860 11 78 59.

Extender Option - Medical Rehabilitation Benefit Details:

    • Benefit Amount:
    • R68,000 per family.
    • Coverage:
    • Medical rehabilitation.
    • Private nursing.
    • Hospice.
    • Step-down facilities.
    • Case Management:
    • All benefits are subject to case management.
    • Eligible Conditions:
    • Illness, injury, accident, or post-surgical procedures causing physical challenges or disabilities.
    • Disabilities: physical, cognitive, mental, sensory, emotional, and developmental.
  • Covered Treatments and Services:
    • Step-down facilities.
    • Occupational therapy.
    • Speech therapy.
    • Physiotherapy.
    • Wound care.
    • Stoma care.
    • Home nursing.
    • Social workers.
  • Eligibility Criteria:
    • Significant life-altering event or injury requiring hospitalization.
    • Discharge plan from treating doctor.
    • Rehabilitation plan.
    • Home environment evaluation.
  • Limitations:
    • Medical schemes cannot provide unlimited funding.
    • Coverage ceases when no further functional benefit is expected or skills are transferred to caregivers.
    • Frail care is excluded.
  • Registration for Treatment in a Step-Down Facility:
    • Letter of motivation from treating doctor with:
    • Diagnosis and ICD-10 code.
    • Current clinical condition.
    • Estimated length of stay.
    • Assessment from a facility with a valid practice number.
    • Treatment plan and tariff codes.
    • Email to subacute@momentum.co.za.
    • 48-hour response time.
    • Appeals via email to subacute@momentum.co.za.
  • Registration for Home Nursing or Hospice:
    • Letter of motivation from treating doctor with:
    • Diagnosis and ICD-10 code.
    • Current clinical condition.
    • Estimated duration of service.
    • Assessment from a facility with a valid practice number.
    • Treatment plan and tariff codes.
    • Email to subacute@momentum.co.za.
    • 48-hour response time.
    • Appeals via email to subacute@momentum.co.za.
  • Registration for Wound Care:
    • Letter of motivation from treating doctor with:
    • Diagnosis and ICD-10 code.
    • Current dated, color photographs of the wound.
    • Estimated dates for wound care.
    • Valid practice number of nursing sister.
    • Tariff codes.
    • List of required items and dressings.
    • Email to subacute@momentum.co.za.
    • 48-hour response time.
    • Appeals via email to subacute@momentum.co.za.
    • Weekly progress reports from treating providers.
  • Coverage:
    • Provides coverage for day-to-day care and treatment following a hospital admission due to specific traumatic events.
  • Eligible Conditions:
    • Severe Burns:
      • Must meet certain qualifying criteria, including severity and FIMS score.
    • Paraplegia and Quadriplegia:
      • Coverage contingent upon the FIMS score.
    • Post-Traumatic Stress Disorder (PTSD):
      • Arising from serious reported crimes.
      • Requires a case number from the police report.
    • Conditions requiring ICU stay of 5 days or more:
      • Near drowning incidents.
      • Poisoning.
      • Severe allergic reactions.
      • External and internal head injuries.
  • Accessing the Benefit:
    • Hospital admission for the traumatic event must be pre-authorized according to emergency protocols.
    • The treating physician must contact the Scheme to obtain authorization for follow-up day-to-day care.
    • A comprehensive treatment plan is required, outlining:
      • Wound care for burns.
      • Nursing services.
      • Visits to general practitioners and specialists.
      • Radiology and pathology services.
  • Contact Information:
    • Web chat: momentummedicalscheme.co.za.
    • Email: member@momentumhealth.co.za.
    • WhatsApp: +27 860 11 78 59.
    • Phone: 0860 11 78 59.
  • Key points:
    • Pre authorization is required for the initial hospital stay, and for the follow up treatments.
    • The treating doctor must provide a treatment plan.
    • FIMS score is used to determine coverage for some conditions.

Extender Option - Dental Benefits Details:

  • 5.1 Out-of-Hospital Basic Dentistry (Extractions, Fillings):
    • Benefit: Unlimited basic dental procedures (within General Rule guidelines).
    • Coverage: 25% of contribution allocated to Savings. Extended Cover after self-funding gap threshold. Momentum Medical Scheme Rate, subject to sub-limits.
  • 5.2 Out-of-Hospital Specialized Dentistry (Bridges, Crowns):
    • Limit: R16,400 per beneficiary, R42,600 per family.
    • Coverage: Includes in- and out-of-hospital specialist accounts.
    • Wisdom Teeth Extraction (Doctor's Office):
      • Anaesthetist and Dental Specialist: Major Medical Benefit (100% of Momentum Medical Scheme Rate).
      • Co-payment: R1,670.
      • Requirement: Pre-authorization.
  • 5.3 In-Hospital Dental and Oral Benefits:
    • Maxillo-facial Surgery (Excluding Implants) and General Anaesthesia (Children under 7):
      • Anaesthetist: 200% of Momentum Medical Scheme Rate.
      • Hospital: Full at negotiated rate.
      • Dental, Specialist, Maxillo-facial Surgeon: Day-to-day Benefits, subject to limits.
      • Co-payment: R1,670 per authorization.
      • Requirement: Pre-authorization.
    • Dentistry Related to Trauma:
      • Hospital: Full at negotiated rate.
      • Anaesthetist, Dentist, Specialist, Maxillo-facial Surgeon: 200% of Momentum Medical Scheme Rate.
    • Extraction of Impacted Wisdom Teeth:
      • Hospital: Major Medical Benefit.
      • Co-payment: R3,300 (day hospitals), R6,150 (other hospitals) per authorization.
      • Anaesthetist: 100% of Momentum Medical Scheme Rate.
      • Dental, Specialist, Maxillo-facial Surgeon: 100% of Momentum Medical Scheme Rate (Major Medical Benefit).
    • Implants and Other In-Hospital Dental Treatment:
      • Benefit: Not covered.
      • Coverage: Payable from Day-to-day Benefits, subject to limits.
  • Key Points:
    • The Extender option utilizes the day to day savings account, and then extended cover after the threshold has been reached for basic dentistry.
    • Specialized dentistry has a set limit.
    • In hospital dental work related to trauma is covered.
    • Implants are not covered.
    • Pre authorization is needed for some procedures.

Momentum GapCover+ and the Extender Option:

  • GapCover Supreme - Shortfall Benefits:
    • Benefit for shortfalls in medical practitioner costs:
      • Covers the difference between medical practitioner fees and what the medical scheme pays, up to three times the medical scheme's reimbursement.
      • For the Extender Option, this equates to 800% of the Momentum Medical Scheme Rate.
      • This also covers shortfalls for specific out-of-hospital procedures (day clinics, etc.).
    • Allied professionals:
      • Covers shortfalls from allied professionals for in-hospital care following a related in-hospital procedure, up to three times the Momentum Medical Scheme reimbursement, with a limit of R2,500 per policy per year.
    • Co-payments:
      • Covers medical scheme co-payments for hospital admissions, procedures, and certain day clinic treatments.
      • Does not cover co-payments for voluntary use of non-Designated Service Providers.
    • Co-payments on oncology treatment:
      • Covers the 20% co-payment applied to oncology treatment after the medical scheme limit is reached.
    • Robotic procedure shortfall benefit:
      • Covers shortfalls for medical practitioner fees in robotic-assisted surgeries, up to three times the medical scheme's reimbursement.
    • Robotic procedure co-payment benefit:
      • Covers medical scheme co-payments for robotic-assisted surgery, up to R12,000 per policy per year.
    • Casualty benefit:
      • Covers up to R24,000 for casualty ward visits within 24 hours of an accident-related emergency.
      • Limited to five visits per family per year.
      • Includes coverage for children eight years or younger in non-accident emergencies (up to R5,000 per visit, three visits per year).
    • Internal prosthesis benefit:
      • Covers shortfalls related to internal prosthesis costs, up to R35,000 per policy per year.
      • Stents and pacemakers are covered up to a sub-limit of R8,000 per claim event.
  • GapCover Supreme - Assist Benefits:
    • Cancer assist benefit:
      • Provides payouts for first-time cancer diagnoses (R8,000 for minimum stage 2 local, R20,000 for minimum stage 2 regional, and an additional R15,000 if oncology treatment exceeds R200,000 within 12 months).
    • Breast reconstruction benefit for non-affected breast:
      • Covers R15,000 per policy per year for cosmetic reconstruction of the non-affected breast after a mastectomy.
    • Accident assist benefit:
      • Provides a payout of R55,000 for death or permanent disability due to an accident.
    • Violent crime benefit:
      • Doubles the Accident Assist benefit to R110,000 if the accident was due to a violent crime.
    • Premium waiver benefit:
      • Covers medical scheme and GapCover premiums (R36,000 upfront) in the event of accidental death or permanent disability of the premium payer.
    • Trauma and bereavement counselling benefit:
      • Covers R800 per session for trauma counselling (up to R30,000 per policy per year).
    • Baby bump benefit:
      • Provides R2,500 upfront for pregnancy-related costs.
  • GapCover Primary:
    • Provides the same medical practitioner short fall cover and copayment cover as the supreme option.
    • Provides a casualty benefit of R12000.
    • Does not include the assist benefits.
  • General Information:
    • Momentum GapCover is only available to Momentum Medical Scheme members.
    • Waiting periods apply (3 months general, 9 months pre-existing, 12 months for cancer and pregnancy).
    • Claims for shortfall benefits are typically processed automatically.
    • Assist benefits require claim form submission.
    • Lists of covered out-of-hospital procedures and allied professionals are provided.
    • Lists of exclusions are provided.
    • Momentum GapCover is not a medical scheme.

Extender Option - International Emergency Travel Cover Details:

  • Coverage Limit:
    • R8.22 million per beneficiary.
    • This limit includes:
      • R15,500 for emergency optometry.
      • R15,500 for emergency dental services.
      • R765,000 for terrorism-related incidents.
  • Eligibility:
    • Coverage is provided for leisure journeys up to 90 days.
  • Co-payment:
    • R2,070 is applicable for each out-patient claim.
  • Pre-notification:
    • Mandatory pre-notification of international travel to Momentum Medical Scheme is required.
    • A fit-to-travel questionnaire completed by the treating doctor in South Africa is also required, especially if:
      • Hospitalized in the past two months.
      • Registered in health management programs.
      • 60 years or older.
      • Pregnant.
      • Have underlying conditions (diabetes, hypertension, etc.).
      • Have immune-suppressive condition.
      • Have chronic respiratory disease.
    • Active oncology treatment, home oxygen dependency, or chronic renal dialysis generally disqualifies travel coverage.
    • Maternity benefits are also excluded.
    • The fit-to-travel confirmation is valid for 30 days.
  • Pre-notification Methods:
    • Momentum App.
    • Web chat (momentummedicalscheme.co.za).
    • Email (member@momentumhealth.co.za).
    • WhatsApp or phone (0860 11 78 59).
  • Required Pre-notification Information:
    • Momentum Medical Scheme membership number.
    • ID and passport numbers of all traveling beneficiaries.
    • Departure and return dates.
    • Countries to be visited and purpose of travel.
  • Consequences of Not Pre-notifying:
    • Loss of international emergency travel cover benefits.
  • Emergency Treatment Abroad:
    • Contact the emergency medical assistance helpline (+27(0)11 541 1263).
    • Helpline will coordinate emergency transport if necessary.
    • Authorized expenses will be settled directly with service providers.
    • For reimbursement of out-of-pocket expenses:
      • Email claims and supporting documents to internationaltravel@momentumhealth.co.za.
      • R2,070 co-payment applies to out-patient claims.
    • Claims for overseas treatment without helpline authorization will not be covered.
    • Day to day benefits can be used for non authorised claims, if they are approved, and submitted within one month of return.
  • Co-payments:
    • No co-payment for in-hospital treatment.
    • R2,070 co-payment for out-patient claims.
  • General Exclusions:
    • Costs during waiting periods and for undisclosed pre-existing conditions.
    • Costs exceeding annual maximums.
    • Injuries from riots, wars, terrorism, etc.
    • Professional speed contests.
    • Services from unregistered providers.
    • Recuperative holidays.
    • Unsubstantiated treatments.
    • Cosmetic procedures.
    • Obesity treatments.
    • Excessive attempted suicide costs.
    • Certain breast and facial surgeries.
    • Unregistered medications.
    • Unregistered institutions.
    • Gum guards and gold dentures.
    • Frail care.
    • General travel expenses.
    • Non-medically necessary costs.
    • Missed appointments.
    • Non-clinical circumcisions and contraceptives.
    • Vasectomy/tubal ligation reversals.
    • Substance abuse injuries.
    • Infertility treatments.
    • Scuba diving beyond 40 meters/cave diving.
    • Maternity or pregnancy related care.
    • Oncology care.
    • Organ transplants.
    • Chronic renal failure.
    • Conditions during waiting periods.
    • Travel against medical advice or with a terminal condition.
    • Failure to obtain a fit-to-fly confirmation.

Extender Option - HIV/Aids Management Programme Details:

  • Programme Registration:
    • Members who test positive for HIV must enroll in the Lifesense HIV programme.
    • Registration ensures access to benefits, comprehensive management, and treatment.
    • Lifesense is appointed by the Scheme to manage the health of the HIV positive member.
    • Lifesense will work with the members healthcare providers to create a treatment plan.
    • Lifesense will provide education, support and access to ARV medication.
  • Post-Exposure Prophylaxis (PEP) Treatment:
    • PEP treatment is available for potential HIV exposure (needle stick injury, sexual assault).
    • Contact Lifesense to access PEP treatment.
  • Anti-Retroviral (ARV) Medication Access:
    • For Extender Option members, ARV medication can be obtained through:
      • Any chronic provider - Any pharmacy
      • Associated chronic provider - Medipost
      • State chronic provider - Medipost
  • Lifesense Contact Details:
    • Tel: 0860 50 60 80
    • Fax: 0860 80 49 60
  • Key Points:
    • Prompt registration with Lifesense is crucial.
    • Confidentiality is maintained throughout the programme.
    • Extender option members have flexible options for where to obtain ARV medication.

Extender Option - Saving on Contributions:

  • Associated Providers for Reduced Contributions:
    • Members on the Extender Option can lower their monthly contributions by choosing the Scheme's Associated providers.
  • Associated Provider Network:
    • This network includes private hospitals, GPs, and pharmacies for chronic prescriptions and medications.
    • Members can also use State facilities for chronic prescriptions, medications, and treatments for maximum savings.
  • Potential Savings:
    • The document highlights potential savings when comparing different provider choices across various plans. While it specifically mentions Custom plans, the principle of savings through associated and state providers applies to the Extender plan as well. You will save money by using associated providers.
    • It is important to understand that the actual saving amount will vary depending on your family size, and the exact associated providers you utilize.
  • Unchanged Benefits:
    • Choosing Associated providers does not change the benefits you are entitled to.
  • Co-payment for Non-Associated Hospital Use:
    • If you choose Associated hospitals for Major Medical Benefits but use non-Associated hospitals, a 30% co-payment will apply.
  • Associated Chronic Provider Requirements:
    • If you choose an Associated chronic provider:
      • Chronic prescriptions must be obtained from an Associated GP.
      • Chronic medication must be obtained from Medipost, according to a specific formulary.
      • Non-compliance results in:
        • 50% reimbursement of the Momentum Medical Scheme Rate for non-Associated GP consultations.
        • 50% reimbursement of the formulary price for non-Medipost medication.
  • State Chronic Provider Requirements:
    • If you choose State facilities as your chronic provider:
      • Chronic medication must be obtained from designated State facilities, following the State formulary.
  • Annual Provider Change:
    • You can change your provider choice once a year during the option change period, effective from January 1 of the following year.
  • Important Note:
    • Momentum Medical Scheme's 2025 benefit and contribution amendments are pending regulatory approval.
  • Key points for Extender option members:
    • Choosing associated providers will lower your monthly contributions.
    • If associated chronic providers are selected, there are strict rules to follow regarding which doctors and pharmacies can be used.
    • There is a large co-payment if associated hospitals are selected, and then not used.

Rheumatoid Arthritis and the Extender Option:

  • Rheumatoid Arthritis (RA) Overview:
    • RA is a chronic autoimmune disorder causing joint inflammation.  
       
    • Symptoms include tender, warm, swollen joints, stiffness, fatigue, fever, and weight loss.  
       
    • Can affect other organs (skin, eyes, lungs, heart, kidneys, etc.).  
       
    • Flares and remissions occur.  
       
    • Can lead to joint deformities.  
       
    • Caused by immune system attacking the synovium.  
       
    • Risk factors: gender, age, family history, smoking, environmental exposures, obesity.  
       
  • Chronic Programme Registration (General Information Applicable to Extender Option):
    • If diagnosed with RA, your doctor should contact the Chronic Medicine Department (0860 11 78 59) to register you.
    • A chronic medicine consultant will manage your treatment plan.
    • Authorization is granted after diagnostic criteria and blood test results are met.
    • You will be informed about formulary coverage and potential co-payments.
    • Medication is obtained from Designated Service Providers (DSPs).
    • Using non-DSPs may result in co-payments.
    • Authorization typically expires after 12 months; renewal is possible.
    • Extender Option members have access to chronic medication and treatment, as per the chronic program rules.
  • Hospitalization (General Information Applicable to Extender Option):
    • For RA-related hospitalization, pre-authorization is required (Momentum App, web chat, email, WhatsApp, or phone).  
       
    • A case manager will monitor your hospital stay.
  • Treatment Plan (General Information Applicable to Extender Option):
    • Once registered, you'll have access to a treatment plan covering tests, doctor consultations, and other necessary benefits.
    • Treatment plans are reviewed for appropriateness and effectiveness.
  • Compliance (General Information Applicable to Extender Option):
    • Obtain chronic medication monthly.
    • Follow prescribed dosage and quantity.
    • Do not miss doses.  
       
    • Claims must include accurate ICD-10 codes.
    • Claims without ICD-10 codes, exceeding frequency limits, or clinically inappropriate treatments may be processed from Day-to-Day Benefits.
  • Contact Information (General Information Applicable to Extender Option):
    • Web chat (momentummedicalscheme.co.za).
    • Email (member@momentumhealth.co.za).  
       
    • WhatsApp or phone (0860 11 78 59).
  • Glossary of Terms (General Information Applicable to Extender Option):
    • Designated service providers (DSPs).  
       
    • Formulary.
    • ICD-10.
    • Prescribed Minimum Benefits (PMBs).  
       
  • Extender Specific notes.
    • The extender option utilizes a savings account, and then extended cover for day to day expenses, so if claims are processed through day to day benefits, it will come from that benefit.
    • The Extender option allows for a wide range of providers, but when using the chronic benefit, the rules regarding DSP's must be followed.
    • It is very important to make sure that ICD-10 codes are on all claims.
       
 

Extender Option - Complementary Product Changes:

  • Momentum HealthSaver Card:
    • From January 1, 2024, HealthSaver funds can only be used with the new HealthSaver Card at approved healthcare merchants.
    • The Momentum Money account and card remain separate for other transactions.
  • Momentum Multiply:
    • Extender Option members continue to have complimentary access to Multiply Inspire.
    • Multiply Inspire:
      • Lifestyle Quiz and Lifestyle Score unlock the Digital Coach Tool.
      • Members earn base-level HealthReturns and partner rewards.
    • Multiply Inspire Plus (Upgrade Option):
      • Double the HealthReturns.
      • Enhanced partner rewards.
      • Family rewards (e.g., up to R3,000 per month for two adults).
      • Up to 60% off with major brands.
  • HealthReturns (Multiply Inspire Plus):
    • Extender Option members can earn up to R1,500 in HealthReturns per adult per month.
    • Earning activities:
      • Health assessments and digital screenings.
      • Fitness assessments and digital screenings.
      • Weekly and Monthly Wins (Active Dayz goals).
      • Weekly and monthly Recharge Goals (sleep quality).
      • Leaderboard challenges.
  • Multiply Premier Changes:
    • Extender Option members on Multiply Premier will automatically transition to Multiply Inspire Plus in January 2024.
    • HealthReturns are only available through Multiply Inspire and Inspire Plus.
  • Momentum GapCover (Supreme):
    • Shortfall benefit increases to R190,000 per insured person annually.
    • Casualty benefit increases to R23,000 per policy annually.
      • Emergency-only casualty ward visit coverage increases to R4,000.
      • Age limit for emergency-only visits for child dependants increases to seven years.
    • Internal prosthesis shortfall benefit increases to R35,000 per policy annually.
      • Stents and pacemakers are covered up to R8,000 per claim event.
    • Baby bump benefit increases to R2,500.
    • Cancer assist benefit increases to R8000 for local malignant cancer.
  • Key Points:
    • The Healthsaver card will be required for healthcare purchases.
    • Extender members get Multiply inspire, and can upgrade to inspire plus.
    • Gap cover benefits are increasing.
    • Momentum and Momentum medical scheme are seperate entities.

Extender Option - 2025 Changes:

  • Major Medical Benefits:
    • Annual sub-limits for in-hospital benefits increased.
    • Co-payments for specialized procedures and wisdom teeth extraction increase.
  • Chronic Benefits:
    • Coverage for 62 chronic conditions, including CDL conditions.
    • Annual limit for additional 36 chronic conditions increased to R13,100 per family.
  • Day-to-Day Benefits:
    • Annual sub-limits for benefits like dentistry and optometry increase.
    • Threshold levels increase for the following:
      • Principal member: R33,400
      • Per adult dependant: R29,000
      • Per child dependant: R9,600 (max of 3 children)
  • Health Platform Benefits:
    • Continued access to free early detection and preventative care benefits.
    • Enhanced dental coverage for preventative care up to R380 per beneficiary.
  • International Emergency Benefit:
    • International emergency benefit co-payment increases to R2,180 per outpatient claim.
  • Key Points:
    • Increased in hospital sub limits.
    • Increased copayments for some procedures.
    • Increased chronic condition coverage limits.
    • Increased day to day sub limits.
    • Increased day to day threshold amounts.
    • Increased dental coverage.
    • Increased international emergency copayment.

Extender Option - Benefit Exclusions:

General Exclusions (Applicable to All Options, Including Extender):

  • Waiting Periods and Undisclosed Pre-existing Conditions:
    • Costs incurred during waiting periods and for conditions not disclosed during application.
  • Exceeding Annual Maximum Limits:
    • Costs exceeding the annual maximum limit set for each benefit category (Annexure B).
  • Injuries from Riots, Wars, Terrorism, etc.:
    • Injuries or conditions arising from intentional participation in riots, civil disturbances, wars, invasions, terrorist acts, or rebellions.
  • Professional Speed Contests/Trials:
    • Expenses related to professional speed contests or trials.
  • Unregistered Healthcare Providers:
    • Services from healthcare providers not registered with the relevant professional body.
  • Recuperative Holidays:
    • Costs associated with holidays for recuperative purposes.
  • Unsubstantiated Treatments:
    • Costs for treatments where efficacy and safety cannot be substantiated.
  • Cosmetic Procedures (Non-Medical):
    • Expenses related to cosmetic procedures or treatments not directly linked to a medical condition, accident, or disease.
  • Obesity Treatments:
    • Costs associated with obesity treatments (unless otherwise specified).
  • Excessive Suicide Attempt Costs:
    • Expenses exceeding three days of hospital management or six outpatient visits for suicide attempts.
  • Specific Cosmetic Procedures:
    • Procedures like breast reduction, breast augmentation, gynaecomastia treatment, otoplasty, and blepharoplasty.
  • Unregistered Medication:
    • Medication not registered with the Medicine Control Council.
  • Unregistered Institutions:
    • Services from unregistered institutions, nursing homes, etc. (except state facilities or hospitals).
  • Gum Guards and Gold Dentures:
    • Expenses for gum guards and gold used in dentures.
  • Frail Care:
    • Costs for frail care services.
  • General Travel Expenses:
    • Travel expenses (except for Emergency rescue and International cover).
  • Non-Medically Necessary Costs:
    • Costs deemed not medically necessary by the Medical Assessor.
  • Missed Appointments:
    • Costs for missed appointments.
  • Non-Clinical Circumcision and Contraceptives:
    • Circumcision (unless clinically indicated) and contraceptive measures or devices.
  • Vasectomy/Tubal Ligation Reversals:
    • Reversals of vasectomies or tubal ligations.
  • Substance Abuse Injuries:
    • Injuries from substance abuse (except for Prescribed Minimum Benefits).
  • Infertility Treatments:
    • Infertility treatments (with some PMB exceptions at state facilities).
  • High-Risk Diving Injuries:
    • Injuries from scuba diving beyond 40 meters or cave diving.

Additional Exclusions for International Emergency Travel Cover (Extender Specific):

  • Maternity Care (During Travel):
    • Care or treatment associated with maternity, including emergencies, if pregnant while traveling.
  • Oncology Care (During Travel):
    • Oncology care or treatment.
  • Organ Transplants (During Travel):
    • Treatment or care related to organ transplants.
  • Chronic Renal Failure (During Travel):
    • Care associated with chronic renal failure.
  • Conditions During Waiting Periods (During Travel):
    • Injuries, illnesses, or emergency conditions during waiting periods.
  • Travel Against Medical Advice:
    • Travel against medical advice, seeking medical attention, or with a pre-existing terminal condition.
  • Failure to Meet Fit-to-Fly Criteria:
    • Failure to meet the criteria in the fit-to-fly questionnaire.

Key points for Extender Option holders:

  • The general exclusions apply to all Momentum Medical Scheme members.
  • When traveling internationally, there are extra exclusions to be aware of.
  • It is very important to make sure to disclose all preexisting conditions when joining the medical aid.

Extender Option - Organ Transplant Programme Details:

  • Programme Overview:
    • Provides coverage for various aspects of organ transplants (pre-transplant evaluations, surgery, post-operative care, rehabilitation, medications, tests).
    • A wellness coach and specialized clinical staff guide members.
    • Pre-authorization is required for coverage.
  • Registration Process:
    • Transplant coordinator at the transplant unit initiates registration.
    • Email to renalcare@momentumhealth.co.za with:
      • Treatment plan and quotation.
      • 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 Requirements):
    • Donor search not covered.
    • Tests for approved donors are covered.
    • In addition to the above, the following is needed:
      • Donor and recipient blood groups.
      • Crossmatch results.
      • Letter from the donor's doctor attesting to their medical fitness.
  • Scheme Review and Approval:
    • Scheme may request additional information (transplant success rates, etc.).
    • If criteria are met, registration for organ transplant benefits is approved.
    • If criteria are not met, the Clinical Governance Organ Transplant panel reviews the application.
  • Authorization for Procedure:
    • After transplant date is confirmed, you and your doctor must call 0860 11 78 59 to authorize the procedure.
    • Provide the acceptance letter reference number.
  • Immunosuppressive Therapy Benefits:
    • Registration is required for coverage of these medications.
    • Doctor contacts the Chronic department (0860 11 78 59, chronic@momentumhealth.co.za, or 031 580 0471).
    • Coverage is available for Prescribed Minimum Benefit (PMB) transplants if registered and approved.
  • Renewal of Organ Transplant Authorization:
    • If waiting for a transplant: Submit a new cost estimate to the Disease Risk Management department.
    • If post-transplant and chronic medication authorization has expired: Send a new prescription to chronic@momentumhealth.co.za or 031 580 0471.
    • Changes to chronic medication require an updated prescription for authorization.
  • Extender Option Specific Notes:
    • If you have selected Associated hospitals as your in-hospital provider, you must use an Associated hospital. Using a different hospital will result in a 30% co-payment on the hospital bill.
    • If you have chosen Associated as your chronic provider, you must get your chronic medication from Medipost, according to the Core formulary. Using other sources may lead to co-payments. If you use a pharmacy other than Medipost, the Scheme will only reimburse 50% of the formulary price.
    • If you have selected State as your chronic provider, you must use State facilities for all post-organ transplant benefits and for obtaining chronic medication (including immunosuppressants).
    • Immunosuppressive therapy for non-PMB transplants is covered under the Extender option, contingent upon registration and approval.
  • Donor Benefits:
    • Extender Option: R53,000 for live donor expenses (including transportation), R26,100 for cadaver donor costs.
    • Donor claims (for non-members) to renalcare@momentumhealth.co.za.
  • Contact Information:
    • Web chat (momentummedicalscheme.co.za).
    • Email (member@momentumhealth.co.za).
    • WhatsApp or phone (0860 11 78 59).
  • Key points for Extender Option members:
    • Adhere to Associated or State provider choices if selected for in-hospital or chronic care.
    • Understand the specific coverage and reimbursement rules for medications.
    • Ensure all necessary documentation is provided for efficient processing.

Extender Option - Chronic Renal Disease Programme Details:

  • Programme Overview:
    • Provides specialized care for members with or at risk of chronic renal disease (CKD).
    • Includes education, lifestyle support, medication management, dietary guidance, haemodialysis, peritoneal dialysis, and kidney transplantation.
  • Registration Process:
    • Healthcare provider completes the chronic renal application form.
    • Email to renalcare@momentumhealth.co.za with:
      • Pathology reports.
      • Urea and electrolytes results.
      • Full blood count and iron profile.
      • Chronic prescription with ICD-10 codes (also emailed to chronic@momentumhealth.co.za).
    • Registration is approved if criteria are met.
  • Medication and Treatment:
    • Chronic renal failure has a specific medication formulary.
    • Healthcare provider is informed of formulary inclusion and co-payments.
    • Comprehensive treatment plan covers consultations, investigations, and assessments.
    • Additional benefits may be allocated as needed.
    • Prescriptions are taken to the pharmacist for claims.
  • Extender Specific Medication Access:
    • If you have selected Associated as your chronic provider, you must obtain your chronic prescription from an Associated GP and your chronic medication from Medipost.  
       
    • If you obtain your chronic medication from any pharmacy other than Medipost, Momentum Medical Scheme will only reimburse 50% of the formulary price.  
       
  • Hospitalization:
    • Pre-authorization is required (Momentum App, web chat, email, WhatsApp, or phone).
    • A case manager coordinates hospital stay.
  • Extender Specific Dialysis and Transplant:
    • If you have chosen State as your chronic provider, you must use State facilities for renal dialysis.
    • If dialysis or treatment is unavailable at a State facility, a letter from the State facility and a motivation letter from your nephrologist are required (email to renalcare@momentumhealth.co.za).
    • A Dialysis and Transplant Programme Coach assists with care.
    • Annual authorization is required for dialysis treatment.
    • Written motivation is required for treatment plan changes (email to renalcare@momentumhealth.co.za).
  • Programme Benefits:
    • Coverage for chronic renal disease medication (Major Medical Benefit, subject to formularies).
    • Coverage for investigations and consultations (Major Medical Benefit).
    • Member engagement and communication (telephone contact).
    • Provider profiling and communication.
    • Easier access to benefits for complications.
  • Contact Information:
    • Web chat (momentummedicalscheme.co.za).
    • Email (member@momentumhealth.co.za).  
       
    • WhatsApp or phone (0860 11 78 59).
  • Glossary of Terms:
    • Designated service providers (DSPs).
    • Formulary.
    • ICD-10.
    • Prescribed Minimum Benefits (PMBs).
  • Key points for Extender Option members:
    • If associated chronic providers are selected, medication must be obtained from Medipost.  
       
    • If state chronic providers are selected, then state facilities must be used for dialysis.
    • Pre authorization is very important for hospital stays.  
       
    • Accurate ICD-10 codes are very important for claims processing.
       
 

Extender Option - Obtaining Authorization for Major Medical Benefits:

  • Services Requiring Pre-authorization:
    • Hospitalization (overnight stays).
    • Day hospital admissions.
    • Specialized procedures or treatments.
    • Advanced imaging services (MRI, CT scans, MRCP, whole-body radioisotope scans, PET scans - specialist referral required).
    • All other Major Medical Benefits.
    • In hospital physiotherapy and occupational therapy.
  • Authorization Process:
    • Pre-authorization is granted after benefit verification and application of Scheme Rules and protocols.
    • If the hospital or doctor obtains authorization, verify potential co-payments or shortfalls (due to non-Designated Service Provider/Preferred Provider use or benefit limits).
  • How to Obtain Pre-authorization:
    • Momentum App.
    • Member call center.
    • WhatsApp: +27860117859.
    • Web chat (momentummedicalscheme.co.za).
    • Email: member@momentumhealth.co.za.
    • Phone: 0860 11 78 59.
    • Record the authorization number and provide it to your healthcare provider(s).
  • Information Required for Pre-authorization:
    • Membership number.
    • Patient name and details.
    • Reason for admission/procedure/scan.
    • Procedure code (CPT), diagnosis code (ICD-10), and tariff code (from doctor).
    • Admission date.
    • Referring GP contact details (if applicable).
    • Specialist contact details.
    • Hospital/day hospital/radiologist name and practice number.
  • Frequently Asked Questions (and Answers):
    • Q: Can authorization be issued on the day of admission?
      • A: No, authorization is required at least 48 hours before admission (except for emergencies).
    • Q: What happens in an emergency?
      • A: You, a family member, or a friend must contact Momentum Medical Scheme within 72 hours of the admission.
    • Q: What if I don’t get authorization in time?
      • A: A 30% co-payment will apply to all related claims. Momentum Medical Scheme will cover 70% of the negotiated tariff (if authorization would have been granted).
    • Q: What if the hospital stay needs to be extended?
      • A: The hospital must contact Momentum Medical Scheme to update the length of stay.
    • Q: How does authorization work for childbirth?
      • A: Contact Momentum Medical Scheme within 30 days of the due date. Notify them of admission date changes within 48 hours of the new admission date.
  • Key points for Extender Option members:
    • Pre authorization is very important.
    • Failure to obtain pre authorization will result in a 30% co payment.
    • Accurate ICD-10 codes are very important.
    • Keep the authorisation number safe, and give it to your healthcare providers.

AdviceFee+ for Extender Option Members (and all individual members):

  • Purpose:
    • A fee agreed upon between the member and their financial advisor for services related to their Momentum Medical Scheme membership.
    • Momentum facilitates the collection and transfer of this fee.
  • Individual Members:
    • The principal member determines the AdviceFee amount.
    • A signed AdviceFee application form is required (for new or existing memberships).
    • Fixed fee options: R62, R117, R155, or R184.
    • Annual review of the fee is possible.
  • Billing and Payment:
    • The AdviceFee is billed separately from Momentum Medical Scheme contributions.
    • Payments are monthly, in advance, on the first of each month.
    • Payment methods: debit order or electronic funds transfer (EFT).
  • Cancellations:
    • The AdviceFee is canceled upon request from the member or financial advisor.
    • It is also canceled if the Momentum Medical Scheme membership is canceled.
    • If unpaid for two consecutive months, it is canceled (new application required for reactivation).
  • Change in Financial Advisor:
    • A new AdviceFee application form is required.
    • Failure to submit the new form results in automatic cancellation.
  • Key Points:
    • The Extender option member has the same options regarding the advice fee, as any other member.
    • The advice fee is seperate from the medical aid contributions.
    • It is very important to make sure that if a member changes financial advisors, that a new form is filled out.

Extender Option - Obtaining Authorization for Major Medical Benefits (2025):

  • Services Requiring Pre-Authorization:
    • Hospitalization (planned admissions).
    • Day hospital admissions.
    • Specialized procedures or treatments.
    • Advanced imaging scans (MRI, CT, MRCP, whole-body radioisotope, PET - specialist referral required).
    • All other Major Medical Benefits.
    • In-hospital physiotherapy and occupational therapy.
    • Auxiliary benefits (limited to Prescribed Minimum Benefits at State Facilities).
  • How Pre-Authorization Works:
    • Momentum Medical Scheme verifies benefits and compliance with Scheme Rules.
    • Verify potential co-payments or shortfalls with the hospital or doctor (due to non-Designated Service Provider/Preferred Provider use or benefit limits).
  • How to Obtain Pre-Authorization:
    • Momentum App.
    • Member Call Center:
      • Web chat (momentummedicalscheme.co.za).
      • WhatsApp: 0860 11 78 59.
      • Email: member@momentumhealth.co.za (include membership number).
      • Phone: 0860 11 78 59.
      • Online help on momentummedicalscheme.co.za (via "Contact Us")
    • Note the authorization number and provide it to your healthcare provider.
  • Required Information for Pre-Authorization:
    • Membership number.
    • Patient details (name, contact).
    • Reason for admission, procedure, or scan.
    • Procedure Code (CPT), Diagnosis Code (ICD-10), and Tariff Code (from treating doctor).
    • Admission date.
    • Referring GP contact details and practice number (if applicable).
    • Specialist contact details and practice number.
    • Hospital, day hospital, or radiologist name and practice number.
  • Frequently Asked Questions (and Answers):
    • Q: Can an authorization number be issued on the day of admission?
      • A: Authorization must be obtained at least 48 hours before admission, except in emergencies.
    • Q: What should I do in an emergency situation?
      • A: Contact Momentum Medical Scheme within 72 hours of admission.
    • Q: What if I don’t receive authorization in time?
      • A: A 30% co-payment will apply. Momentum Medical Scheme will cover 70% of the negotiated tariff.
    • Q: What if the length of stay needs to be extended beyond the authorized period?
      • A: The hospital must contact Momentum Medical Scheme to update the length of stay.
    • Q: How does authorization work for childbirth?
      • A: Contact Momentum Medical Scheme within 30 days of your due date for confinement authorization. Notify them within 48 hours of the new date if the admission date changes.
  • Key points for Extender Option members:
    • Pre authorization is very important.
    • Failure to obtain pre authorization will result in a 30% co payment.
    • Accurate ICD-10 codes are very important.
    • Keep the authorisation number safe, and give it to your healthcare providers.
    • The Extender option, like all other options, requires pre-authorisation for the listed medical events.

  • HealthSaver and the Extender Option:

    • General HealthSaver Features (Applicable to All Members, Including Extender):
      • HealthSaver helps you save for medical expenses (vitamins, cosmetic surgery, etc.).  
         
      • Potential to earn up to 10% interest on positive balances (based on Healthy Heart Score and Active Dayz/fitness assessment).  
         
      • Annual administration fee of R40.
      • Can be used for treatments not covered by your medical scheme option.  
         
    • How Extender Option Members Can Use HealthSaver Funds:
      • Medical Scheme Contributions: If you pay your contributions directly, you can use HealthSaver to pay them.  
         
      • Healthcare Expenses:
        • GP visits, consultations, and prescription medications (with NAPPI codes).  
           
        • Services from registered healthcare providers (with tariff codes).  
           
        • Expenses exceeding medical scheme benefits (e.g., specialized dental care).
        • Treatments excluded from your medical scheme (e.g., cosmetic surgery).  
           
        • Co-payments (hospitalizations, MRI/CT scans, medications).  
           
        • Virtual consultations (Hello Doctor).
        • Fitness assessments (Multiply network).
        • Fitness apps/devices (Multiply compatible).
        • Reimbursement for gym fees (Multiply-affiliated gyms).  
           
      • HealthSaver Card:
        • Payments at doctors, hospitals, pharmacies, dentists, etc.
        • Medical services, equipment, and supplies.
        • Orthopedic goods, healthcare practitioners (osteopaths, etc.).
        • Vision care, nursing care, ambulance services, veterinary services.
      • HealthReturns:
        • Extender members (if on Multiply Inspire Plus) can earn HealthReturns.  
           
        • Activities: Lifestyle Quiz, health/fitness assessments, activity goals, leaderboard challenges.  
           
      • Healthcare Vouchers:
        • Option to donate vouchers for GP, eye, or dental care to someone in need (NetcarePlus).  
           
      • Retirement Savings:
        • Option to transfer excess funds to FundsAtWork (certain conditions apply).
    • HealthSaver Account Management (Applicable to Extender):
      • Eligibility: All Momentum Medical Scheme members (including Extender).  
         
      • Sign-up: Momentum App.
      • FICA verification required.
      • Contributions:
        • Not mandatory; can just receive HealthReturns.
        • Optional monthly contributions (min R100, max R11,500 via debit order).
        • Credit facility available (annual limit based on monthly contributions; max R36,000).
        • Lump sum deposits allowed (AML audits for R50,000+).
      • Fees:
        • R40 annual administration fee (January).
        • HealthSaver Card fees (issue, delivery, annual).
      • Restrictions:
        • No cash withdrawals or transfers.  
           
      • Account Closure:
        • Positive balance paid out after 4-month waiting period.
        • HealthReturns forfeited on closure.
        • Administration fees for dormant accounts.
      • Account Suspension:
        • HealthReturns stored for 3 months; forfeited if not reinstated.
    • Credit Facility (Applicable to Extender):
      • Application: Real-time.
      • Credit terms acceptance required (60 days for members linked to employer groups, 30 days for individuals).
      • Full 12-month credit initially available; adjusted in subsequent years.
      • Interest: Prime + 6% (may be reduced by Healthy Heart Score and activity level; potentially to 0%).
      • Interest calculation: Monthly, based on daily balance changes.
      • HealthReturns Booster:
        • Can be used for dependent children's education (conditions apply).  
           
    • Claims (Applicable to Extender):
      • Claims for yourself and dependents.
      • Valid practice number and tariff/NAPPI code required.
      • Option to claim at cost or up to 200% of the Momentum Medical Scheme Rate.
      • Fitness device claims: Invoice and proof of payment to claims@momentumhealth.co.za.  
         
      • Gym fee claims: Bank statement/invoice (Multiply-affiliated gym) to claims@momentumhealth.co.za.  
         
      • HealthSaver Card refunds: Healthcare provider account, SMS reference, POS receipt to refundhealthsaver@momentum.co.za.
    • Tax Implications (Applicable to Extender):
      • HealthSaver contributions are from after-tax income (not tax-deductible).
      • Most expenses are tax-deductible.
      • HealthSaver tax statement provided.
      • Non-deductible items (gym fees, fitness devices) not on tax certificate.
    • Paying Medical Scheme Contributions from HealthSaver (Applicable to Extender):
      • If you pay contributions directly (not via salary deduction).
      • Contact Momentum (web chat, email, WhatsApp, phone).  
         
      • Specify number of months.
      • Request 7+ days before 1st of the month.
      • Funds from HealthSaver (actual and Booster) can be used.
      • Ends December 1st.
    • Transferring Funds to FundsAtWork (Applicable to Extender):
      • Option to invest excess funds for retirement.  
         
      • Annual transfer in November (if balance > R5,000, excluding credit facility).
      • Funds become an additional voluntary contribution (AVC).
    • Adding Funds to HealthSaver (Applicable to Extender):
      • Ad-hoc deposits via EFT (banking details provided).
      • Use correct reference (HS + membership number).
      • Email proof of payment to mhretail@momentum.co.za.
    • Key points for Extender Option members:
      • Healthsaver is a great way to pay for day to day expenses.  
         
      • You can earn up to 10% interest.  
         
      • You can pay your medical aid from your healthsaver account.  
         
      • You can pay for a wide range of healthcare products.
         
         
         
    These are excluded under the extender option 
    Prescribed Minimum Benefits
    Notwithstanding the limitations and exclusions set out below, beneficiaries shall be entitled to the Prescribed Minimum
    Benefits.
    Benefits excluded
    General exclusions mentioned in this paragraph are not affected by any specific exclusions. Unless otherwise decided by
    the Scheme (and with the express exception of medicine or treatment approved and authorised in terms of any health
    management programme contracted to the Scheme), expenses incurred in connection with any of the following will not be
    paid by the Scheme:
    1. All costs incurred during waiting periods and for
    conditions which existed at the date of application for
    membership of the Scheme but were not disclosed;
    2. All costs that exceed the annual maximum allowed for
    the particular category as set out in Annexure B of the
    Scheme Rules, for the benefit to which the beneficiary
    is entitled in terms of the Scheme Rules;
    3. Injuries or conditions sustained during wilful
    participation in a riot, civil commotion, war, invasion,
    terrorist activity or rebellion;
    4. Professional speed contests or professional speed
    trials (professional defined as where the beneficiary’s
    main form of income is derived from partaking in these
    contests);
    5. Health care provider not registered with the recognised
    professional body constituted in terms of an Act of
    parliament;
    6. Holidays for recuperative purposes, whether deemed
    medically necessary or not, including headache and
    stress relief clinics;
    7. All costs for treatment if the efficacy and safety of such
    treatment cannot be proved;
    8. All costs for operations, medicine, treatments and
    procedures for cosmetic purposes or for personal
    reasons and not directly caused by or related to
    illness, accident or disease. This includes the costs of
    treatment or surgery related to transsexual procedures;
    9. Obesity;
    10. Costs for attempted suicide that exceed the Prescribed
    Minimum Benefits limits;
    11. Breast reduction and breast augmentation,
    gynaecomastia, otoplasty and blepharoplasty;
    12. Medication not registered by the Medicine Control
    Council;
    13. Costs for services rendered by any institution, nursing
    home or similar institution not registered in terms of
    any law (except a State facility/hospital);
    14. Gum guards and gold used in dentures;
    15. Frail care;
    16. Travelling expenses, excluding benefits covered by
    Emergency rescue and International cover;
    17. All costs, which in the opinion of the Medical Assessor
    are not medically necessary or appropriate to meet the
    health care needs of the patient;
    18. Appointments which a beneficiary fails to keep;
    19. Circumcision, unless clinically indicated, and any
    contraceptive measures or devices;
    20. Reversal of Vasectomies or tubal ligation (sterilisation);
    21. Injuries resulting from narcotism or alcohol abuse
    except for the Prescribed Minimum Benefits;
    22. Infertility treatment that is included as Prescribed
    Minimum Benefits will be covered in State facilities,
    subject to paragraph 4 of Annexure D of the Scheme
    Rules;
    23. The cost of injury and any other related costs as a result
    of scuba diving to depths below 40 metres and cave
    diving
     
 

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