Focus on Chronic Obstructive Pulmonary Disease (COPD)

What is COPD? 

Chronic Obstructive Pulmonary Disease (COPD) is a serious lung condition that significantly impairs an individual's ability to breathe. This disease arises from long-term damage to the lungs, which often occurs over many years, and is characterized as a progressive ailment, meaning that it tends to worsen over time. COPD encompasses two primary conditions: chronic bronchitis and emphysema. In this condition, the airways in the lungs become inflamed, and the air sacs, known as alveoli, sustain damage. As a result, the airways narrow, making it increasingly difficult for individuals to inhale and exhale effectively. The predominant cause of COPD is cigarette smoking, which is responsible for the majority of cases.

The signs and symptoms of COPD

• Wheezing, particularly during exhalation, is a common symptom of COPD. This high-pitched whistling sound occurs when the airways are constricted.
• Breathlessness can manifest both during physical activity and at rest. Patients may find it challenging to engage in everyday tasks without experiencing shortness of breath.
• A tight sensation in the chest is frequently reported, which can contribute to feelings of anxiety and discomfort.
• Coughing is another prevalent symptom, often accompanied by the production of mucus. This chronic cough can be persistent and bothersome.
• Individuals with COPD may notice an increase in the production of mucus or phlegm, which can exacerbate breathing difficulties and lead to further complications.

Possible causes of COPD

• Smoking is the leading cause of COPD, accounting for the vast majority of cases. This includes not only traditional cigarette smoking but also the use of other tobacco products such as cigars and pipes, especially when the smoke is inhaled.
• Second-hand smoke exposure is another significant risk factor. Even individuals who do not smoke themselves can develop COPD if they live with a smoker and inhale the smoke regularly.
• Environmental factors, such as air pollution and exposure to harmful fumes, can contribute to the development of COPD. Occupational hazards, including inhaling dust or toxic substances, can also increase the risk.
• Although less common, asthma can lead to COPD if it is not adequately managed. Over time, untreated asthma can result in lasting damage to the lungs.

How to register on the chronic programme

If you have been diagnosed with Addison’s disease, it is important to initiate the process of registration for the Chronic Medicine Management Programme. To do this, please ask your doctor to reach out to our Chronic Medicine Department by calling 0860 11 78 59. The chronic medicine consultant will work closely with your healthcare provider to coordinate your treatment plan. Once all necessary diagnostic criteria are met and blood test results are submitted, your treatment will be reviewed and approved. You will be informed whether your prescribed treatment is covered under the Momentum Medical Scheme formulary or if there will be a need for a co-payment. After receiving authorization, you can take your prescription to an approved service provider to obtain your medication, and the claim can be processed accordingly. A designated service provider (DSP) refers to a healthcare professional or facility that is the preferred choice of the medical scheme for members seeking diagnosis, treatment, or care for conditions classified as Prescribed Minimum Benefits. If you choose to use a provider outside of the designated network, a co-payment may apply. Typically, the authorization is valid for 12 months. If your medication regimen remains unchanged, your doctor or pharmacist can contact us again at 0860 11 78 59 to renew the authorization. The same process will be followed for any modifications or additions to your treatment plan.

For additional information regarding your chronic benefits and where to obtain chronic medications and treatments, please click here.

Hospitalization

In the event that you require hospitalization due to complications related to cardiac failure, it is crucial to follow the appropriate steps for pre-authorization. You can log into the Momentum App, utilize the web chat feature available on momentummedicalscheme.co.za, email us at [e-mail], send us a WhatsApp message, or call us directly at 0860 11 78 59 to request pre-authorization. We will assign a case manager to oversee and follow up on your hospitalization process.

Treatment plan

Once you are officially registered in the program, you will gain access to a comprehensive treatment plan. This plan may encompass coverage for various necessary medical services, including diagnostic tests, consultations with healthcare providers, and other benefits deemed medically essential by your doctor. These services will undergo evaluation by our clinical team to ensure that they are appropriate and align with your health needs.

Compliance

Maintaining compliance with your treatment plan is vital for your health. You are required to:

• Obtain your chronic medication on a monthly basis to ensure that you have an uninterrupted supply of necessary treatments.
• Adhere strictly to the dosage and quantity prescribed by your healthcare provider to maximize the effectiveness of your medication.
• Ensure that you do not miss any doses, as this is critical not only for compliance but also for your overall health and well-being. Missing doses can lead to serious health implications and hinder the effectiveness of your treatment.

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

It is essential for all claims submitted to include the correct ICD-10 codes, which are diagnostic codes used to identify the nature of the claim accurately. This ensures that your claim is processed correctly and paid from the Chronic Benefit.

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

• The claims are submitted without the relevant ICD-10 codes, which can lead to processing issues.
• You have exceeded the frequency limits set for consultations or tests, which may necessitate the use of alternative benefits.
• The treatment being claimed is not considered clinically appropriate based on established medical guidelines.

Contact us

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

Glossary of terms

Designated service providers are part of the Momentum Medical Scheme's network, which includes a variety of healthcare professionals such as general practitioners, specialists, and state facilities. These providers are selected based on their ability to diagnose and treat our members for conditions covered under the Prescribed Minimum Benefits.

A formulary is a specific list of medications that are covered under your health plan option. This list serves as a guideline for doctors to prescribe the appropriate medications for managing chronic conditions.

The term ICD-10 refers to the International Classification of Diseases, 10th Revision, which provides diagnostic codes for various health conditions.

Prescribed Minimum Benefits represent a set of essential health benefits that all medical schemes in South Africa are mandated to cover according to the Medical Schemes Act 131 of 1998 and its associated regulations. To qualify for these benefits:

• Your medical condition must be included in the defined list of Prescribed Minimum Benefit conditions.
• The treatment required must align with the services outlined within the defined benefits.
• You must utilize the Scheme’s Designated Service Providers as specified in the guidelines.

If you choose to seek services from non-designated service providers voluntarily, the Scheme will reimburse you up to the Momentum Medical Scheme Rate, and relevant co-payments will apply. However, if you require emergency medical care from non-designated providers, this is considered involuntary, and co-payments will be waived.