Focus on diabetes

What is diabetes?

Diabetes is a metabolic disorder that significantly impacts how the body processes digested food for growth and energy. When we consume food, it is primarily broken down into glucose, which is the sugar found in the bloodstream. This glucose serves as the body's primary energy source. After the digestion process, glucose enters the bloodstream and is utilized by cells for various functions, including growth and energy production. However, for glucose to effectively enter the cells, insulin must be present. Insulin is a vital hormone produced by the pancreas, which is a large gland located behind the stomach and plays a crucial role in regulating blood sugar levels.

Diabetes is characterized as a chronic condition that leads to elevated levels of sugar (glucose) in the bloodstream. Normally, insulin produced by the pancreas works to lower blood glucose levels. However, diabetes occurs when there is either an absence or insufficient production of insulin, or when the body cannot effectively use the insulin that is available. This results in the body being unable to maintain normal glucose levels, leading to various health complications.

Symptoms of diabetes may include:

• Increased urine output: Individuals may notice they need to urinate more frequently than usual, which can be a sign of excess glucose in the bloodstream.
• Excessive thirst: This symptom often accompanies increased urination, as the body attempts to compensate for fluid loss.
• Weight loss: Unexpected weight loss can occur as the body begins to use fat and muscle for energy instead of glucose.
• Hunger: Despite eating, individuals may feel an increased sense of hunger due to the body's inability to effectively use glucose.
• Fatigue: A lack of energy and persistent tiredness can result from the body's struggle to utilize glucose for fuel.
• Skin problems: Diabetes can lead to skin issues, including dryness or infections.
• Slow healing wounds: Cuts and bruises may take longer to heal, which can be a sign of poor circulation and high blood sugar levels.
• Yeast infections: Increased sugar levels can create an environment conducive to yeast infections.
• Blurred vision: High blood sugar can affect the lenses of the eyes, leading to temporary vision changes.
• Tingling or numbness in the feet or toes: Nerve damage caused by diabetes can result in these sensations, known as neuropathy.

Different types of Diabetes

Type 1 diabetes is a form of diabetes that was previously known as juvenile diabetes, primarily because it often develops in children and young adults. However, it can also manifest in adults. In type 1 diabetes, the body ceases to produce insulin or produces it in insufficient quantities. This occurs because the immune system mistakenly attacks and destroys the insulin-producing cells in the pancreas. As a result, individuals with type 1 diabetes must rely on external insulin administration to manage their blood sugar levels effectively.

Type 2 diabetes occurs when the body either does not produce enough insulin or the cells become resistant to insulin's effects. This resistance means that glucose remains in the bloodstream instead of being utilized as energy, leading to elevated blood sugar levels. Type 2 diabetes is more common than type 1 and is often associated with lifestyle factors such as obesity, inactivity, and poor diet.

Gestational diabetes is a type of diabetes that can develop during pregnancy. In this condition, some women experience significantly high levels of glucose in their blood, and their bodies are unable to produce enough insulin to facilitate the transport of glucose into their cells. This results in progressively increasing blood glucose levels. Diagnosis typically occurs during routine screenings in pregnancy.

Diabetes insipidus is a rare condition that differs from the more common types of diabetes. It occurs when the kidneys fail to conserve water, leading to excessive thirst and frequent urination. This condition is not related to blood sugar levels but rather to the body's regulation of water balance.

How to register on the chronic programme

If you have been diagnosed with Addison’s disease, it is essential to initiate the registration process for the Chronic Medicine Management Programme. To do this, please ask your doctor to reach out to our Chronic Medicine Department at 0860 11 78 59. The chronic medicine consultant will collaborate with your physician regarding your treatment plan. Once the necessary diagnostic criteria have been satisfied and relevant blood results submitted, treatment approval will follow. You will be informed whether your treatment is covered under the Momentum Medical Scheme formulary or if you will be required to make a co-payment. Upon receiving authorization, you can present your prescription to your designated service provider to obtain your medication, and the claim can then be submitted for processing. A designated service provider (DSP) is a healthcare provider, such as a doctor, pharmacist, or hospital, that is preferred by the medical scheme for diagnosing, treating, or caring for a Prescribed Minimum Benefit condition. If you choose not to utilize the DSP and opt for a different provider, a co-payment may be applied. Please note that the authorization typically expires after 12 months. If there are no changes to the medication you require, your doctor or pharmacist can contact us at 0860 11 78 59 to renew the authorization. The same procedure applies if there are any modifications or additions needed for your authorization.

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

Hospitalization

Should you require hospitalization due to complications from cardiac failure, it is important to initiate the pre-authorization process. You can do this by logging into the Momentum App, using the web chat feature available on momentummedicalscheme.co.za, emailing us at [e-mail], sending a WhatsApp message, or calling us at 0860 11 78 59. A case manager will be assigned to monitor your hospital stay and ensure that your needs are met.

Treatment plan

Once you are successfully registered in the chronic programme, you will gain access to a comprehensive treatment plan. This plan may encompass coverage for necessary medical tests, consultations with doctors, and other benefits that your healthcare provider deems medically essential. Each aspect of your treatment plan will be evaluated by our clinical team to confirm its appropriateness and effectiveness for your health needs.

Compliance

To ensure the best possible health outcomes, it is crucial that you adhere to the following compliance guidelines:

• Obtain your chronic medication on a monthly basis to maintain consistent treatment.
• Take your medication exactly as prescribed by your doctor, adhering to the specified dosage and quantity.
• Do not miss a dose of your medication, as this is vital not only for compliance but also for your overall health and well-being. Missing doses can have serious implications for your health.

Please ensure your claims include the appropriate ICD-10 code

It is imperative that all claims submitted include the correct ICD-10 codes (diagnostic codes). This allows us to accurately identify and process the claim through the Chronic Benefit.

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

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

Contact us

If you have any questions or need 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: Momentum Medical Scheme collaborates with a network of designated service providers, which includes associated general practitioners and specialists, as well as state facilities, depending on individual circumstances. This network is utilized to diagnose and treat our members for conditions classified under the Prescribed Minimum Benefits.

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

ICD-10 refers to the International Classification of Diseases, 10th Revision, which is the diagnosis code used for medical billing and record-keeping.

Prescribed Minimum Benefits are a set of essential health benefits that all medical schemes in South Africa are mandated to provide coverage for, as stipulated by the Medical Schemes Act 131 of 1998 and its associated regulations. To access these benefits, certain criteria must be met:

• Your medical condition must qualify for coverage and must be part of the defined list of Prescribed Minimum Benefit conditions.
• The treatment required must align with the treatments outlined in the defined benefits.
• You must utilize the Scheme’s Designated Service Providers. For more information regarding Designated Service Providers, please refer to the definition provided on page 2.

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