Benefits and coverage offered by the Summit option (2025) – Momentum

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

The Summit Option offers comprehensive coverage for hospitalization, chronic conditions, and day-to-day healthcare. This option ensures members can access essential medical care without the stress of annual limits. Additional benefits are available through the Momentum HealthSaver+ product and the Health Platform Benefit, promoting overall health and wellness.

Overall day-to-day Benefits:

The overall day-to-day limit for the Summit Option is R33,000 per beneficiary per year, which is combined for both day-to-day and chronic conditions.

On the Summit Option, claims are paid at 100% of the Momentum Medical Scheme Rate, subject to certain sub-limits and an overall day-to-day limit of R33 000 per beneficiary.

Key Benefits

Major Medical Benefits

Provider: Any hospital
Limit: No overall annual limit
Coverage:
- Specialists: Full coverage for associated specialists; other specialists are covered up to 300% of the Momentum Medical Scheme Rate.
- Hospital Accounts: Fully covered at the agreed rate with the hospital group.
- Specialized Procedures/Treatment: Certain procedures and treatments covered (subject to approval).

Coverage Details:

Hospitalization: Covers all related costs from admission to discharge, given pre-authorization.
Specialized Procedures: Includes treatments not requiring hospital admission, provided they are clinically appropriate and authorized.
Co-payment: A 30% co-payment applies if pre-authorization is not obtained.

Chronic and Day-to-Day Benefits

Chronic Coverage:
- Provider: Any provider, supported by a comprehensive formulary.
- Chronic Conditions Covered: 62 conditions, including 26 conditions listed under Prescribed Minimum Benefits (PMB), with no annual limit.
- Additional Chronic Conditions: 36 conditions covered, but contributions apply to the R33,000 annual day-to-day limit.
- Day-to-Day Coverage: Covers general healthcare, including doctor visits and prescribed medications, subject to the R33,000 limit.

Day-to-Day Benefits

Provider: Any provider
Limit: R33,000 per beneficiary per year (combined for both day-to-day and chronic conditions).
Sub-limits: Specific sub-limits apply annually, adjusted pro-rata if enrollment occurs later in the year.

Health Platform Benefit

This benefit promotes wellness and preventative care, with coverage for:

Preventive Care: Screening tests and early detection.
Maternity Program: Comprehensive maternity support.
Health Education and Advice: Access to health resources and consultations.

Coverage for Specialized Procedures and Treatments

Key Procedures and Treatments:

No Annual Limit:
- Trauma Care: Includes expenses for treatment after traumatic events like drowning, poisoning, and severe injuries.
- Dialysis and Oncology: Includes no limit on renal dialysis and oncology treatments.
- Organ Transplants: Full coverage for transplant recipients; coverage for donors is also provided (R27,500 for cadaver costs, R56,000 for live donor costs).

Specific In-Hospital Benefits:

Dental and Oral Care:
- Maxillo-facial Surgery: Covered up to 300% of the Momentum Medical Scheme Rate.
- Trauma-related Dental Treatment: Paid from available day-to-day benefits.
- Implants: Paid from day-to-day benefits, subject to limits.
Maternity and Neonatal Care:
- No annual limit for maternity confinements and neonatal intensive care.
Medical Scans:
- MRI, CT, PET scans: No annual limit, but a R2,900 co-payment per scan applies.
Prostheses:
- Internal Prostheses: Covered up to R234,000 per beneficiary per year.
- External Prostheses: Covered up to R30,600 per family.

Mental Health

Psychiatry and Psychology: R48,400 per beneficiary.

Medical Rehabilitation and Nursing

Coverage: R72,000 per family for rehabilitation, private nursing, hospice, and step-down facilities (subject to case management).

Emergency Medical Transport

South Africa: No annual limit with Netcare 911.
International: R9,010,000 per beneficiary per 90-day journey, including emergency optometry, dentistry, and terrorism cover (co-payment applies).

Chronic Benefit

Key Features:

Provider: Any provider
Coverage:
- Covers 62 chronic conditions, including 26 PMB-listed conditions with no annual limit.
- Additional 36 conditions are covered but subject to the R33,000 annual day-to-day limit.

Registration Requirement:

Chronic Management Program: Members must register and gain approval for chronic benefits.

Day-to-Day Benefit

Key Features:

Provider: Any provider
Limit: R33,000 per beneficiary per year (combined with chronic conditions).
Sub-limits: Specific sub-limits apply annually, adjusted pro-rata based on enrollment.

Summary: The Summit Option offers comprehensive coverage across various healthcare needs, including hospitalization, specialized treatments, chronic care, and day-to-day benefits, ensuring members have access to essential services without hitting annual limits. The Health Platform Benefit further enhances overall wellness by covering preventive care, maternity, and health education.

General Healthcare Services

Acupuncture, Homeopathy, Naturopathy, and Related Therapies

Coverage: Up to R9,420 per family
Subject to: Overall day-to-day limit of R33,000 per beneficiary
Includes: Acupuncture, homeopathy, naturopathy, herbology, audiology, occupational therapy, speech therapy, chiropractors, dieticians, biokinetics, orthoptists, osteopathy, audiometry, chiropody, physiotherapy, and podiatry.

Mental Health (Psychiatry and Psychology)

Coverage: R28,300 per family
Subject to: Overall annual day-to-day limit of R33,000 per beneficiary

Dentistry

Basic Dentistry (Extractions, Fillings)
- Coverage: Subject to overall annual day-to-day limit of R33,000 per beneficiary
Specialized Dentistry (Bridges, Crowns)
- Coverage: R19,800 per beneficiary, R47,700 per family
- Subject to: Overall annual day-to-day limit of R33,000 per beneficiary
- Note: In- and out-of-hospital dental specialist accounts accumulate toward the limit.
Impacted Wisdom Teeth Extraction
- Coverage: Covered under the Major Medical Benefit at 100% of Momentum Medical Scheme Rate
- Condition: Pre-authorization required.

External Medical and Surgical Appliances

Coverage: R38,400 per family, with a sub-limit of R22,200 for hearing aids
Subject to: Overall annual day-to-day limit of R33,000 per beneficiary

General Practitioners and Specialists

Coverage: Subject to overall annual day-to-day limit of R33,000 per beneficiary

Optical and Optometry (Including Contact Lenses and Refractive Eye Surgery)

Coverage: R5,800 per beneficiary
- Sub-limit for frames: R2,950
Subject to: Overall annual day-to-day limit of R33,000 per beneficiary

Pathology and Radiology

Pathology: Subject to overall annual day-to-day limit of R33,000 per beneficiary
Radiology: Subject to overall annual day-to-day limit of R33,000 per beneficiary

Advanced Scans

Coverage: MRI, CT, MRCP, whole body radioisotope, and PET scans
Co-payment: R2,900 per scan
Condition: Pre-authorization required
Covered under: Major Medical Benefit

Prescribed Medication

Coverage: R25,700 per beneficiary, R42,300 per family
Subject to: Overall annual day-to-day limit of R33,000 per beneficiary
Note: Over-the-counter medication, including prescribed vitamins and homeopathic medicine, is not covered.

Preventative Care

Immunizations and Vaccines

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 aged 60+, and high-risk beneficiaries
- Frequency: Once per year
Tetanus Diphtheria Injection:
- Eligibility: All beneficiaries
- Frequency: As needed
Pneumococcal Vaccine:
- Eligibility: Beneficiaries aged 60+ and high-risk beneficiaries
- Frequency: Once per year

Early Detection Tests

Preventative Dental Care:
- Coverage: R380 per beneficiary
- Frequency: Once per year
- Eligibility: All beneficiaries
Pap Smear Consultation:
- Eligibility: Women aged 15 and older
- Frequency: As required by the type of pap smear
Pap Smear (Pathologist):
- Eligibility: Women aged 15 and older
- Frequency: Once per year
HPV PCR Screening Test:
- Eligibility: Women aged 21 to 65
- Frequency: Once every 3 years (Follow-up LBC if high risk is indicated)
Mammogram:
- Eligibility: Women aged 38 and older
- Frequency: Once every 2 years
DEXA Bone Density Scan:
- Eligibility: Beneficiaries aged 50 and older
- Frequency: Once every 3 years
General Physical Examination:
- 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:
  - Men aged 40-49: Once every 5 years
  - Men aged 50-59: Once every 3 years
  - Men aged 60-69: Once every 2 years
  - Men aged 70+: Once a year
Health Assessment:
- Tests Included: Blood pressure, cholesterol, blood sugar (finger prick), height, weight, and waist circumference
- Eligibility: All principal members and adult beneficiaries
- Frequency: Once per year
Cholesterol Test (Pathologist):
- Eligibility: Principal members and adult beneficiaries
- Condition: Total cholesterol level of 6 mmol/L or higher
- Frequency: Once per year
Blood Sugar Test (Pathologist):
- Eligibility: Principal members and adult beneficiaries
- Condition: Blood sugar level of 11 mmol/L or higher
- Frequency: Once per year
Glaucoma Test:
- Eligibility:
  - Aged 40-49: Once every 2 years
  - Aged 50+: Once per year
HIV Test (Pathologist):
- Eligibility: Beneficiaries aged 15 and older
- Frequency: Once every 5 years

Maternity Care Benefits

Doula Benefit:
- Eligibility: Women registered on the program
- Frequency: 2 visits per pregnancy
Antenatal Visits:
- Eligibility: Women registered on the program
- Frequency: 12 visits
Online Antenatal and 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 (after childbirth, 2 weeks, and 6 weeks)
Urine Tests (Dipstick):
- Eligibility: Women registered on the program
- Frequency: Included in antenatal visits

Pathology Tests for Maternity

Tests Covered: Antiglobin, blood group, creatinine, full blood count, platelet count, Rhesus factor, and Rubella antibody
- Eligibility: Women registered on the program
- Frequency: 1 test
Glucose Strip and Hemoglobin Estimation:
- Eligibility: Women registered on the program
- Frequency: 2 tests
Urinalysis:
- Eligibility: Women registered on the program
- Frequency: 12 tests
Urine Tests (Microscopic Exams, Culture):
- Eligibility: Women registered on the program
- Frequency: As indicated
Pregnancy Scans:
- Eligibility: Women registered on the program
- Frequency: 2 pregnancy scans (3D/4D scans are covered at the rate of 2D scans)
Paediatrician Visits:
- Eligibility: Babies up to 12 months registered on the program
- Frequency: 2 visits in the baby’s first year
24-hour Emergency Health Advice:
- Eligibility: All beneficiaries
- Frequency: As needed

Momentum Summit Option 2025: Detailed Overview

The Summit Option provides comprehensive coverage for a wide range of healthcare needs, including hospitalization, chronic conditions, and day-to-day medical expenses.

I. Core Benefits

Comprehensive Coverage: The Summit Option aims to provide members with access to essential medical care without the constraints of typical annual limits.
Momentum HealthSaver+ and Health Platform Benefit: Members can access additional benefits through the Momentum HealthSaver+ product and the Health Platform Benefit, which promotes overall health and wellness.

II. Major Medical Benefits

Provider: Any hospital
Limit: No overall annual limit
Coverage:
- Specialists:
  - Associated specialists: Full coverage
  - Other specialists: Covered up to 300% of the Momentum Medical Scheme Rate
- Hospital Accounts: Fully covered at the agreed rate with the hospital group
- Specialized Procedures/Treatment: Covered (subject to approval)
Coverage Details:
- Hospitalization: Covers all related costs from admission to discharge, provided that pre-authorization is obtained.
- Specialized Procedures: Covers treatments that do not require hospital admission, provided they are clinically appropriate and authorized.
- Co-payment: A 30% co-payment applies if pre-authorization is not obtained.
Specific In-Hospital Benefits:
- Dental and Oral Care:
  - Maxillo-facial Surgery: Covered up to 300% of the Momentum Medical Scheme Rate.
  - Trauma-related Dental Treatment: Paid from available day-to-day benefits.
  - Implants: Paid from day-to-day benefits, subject to limits.
- Maternity and Neonatal Care: No annual limit for maternity confinements and neonatal intensive care.
- Medical Scans: MRI, CT, PET scans: No annual limit, but a R2,900 co-payment applies per scan.
- Prostheses:
  - Internal Prostheses: Covered up to R234,000 per beneficiary per year.
  - External Prostheses: Covered up to R30,600 per family.
- Mental Health: Psychiatry and Psychology: R48,400 per beneficiary.
- Medical Rehabilitation and Nursing: R72,000 per family for rehabilitation, private nursing, hospice, and step-down facilities (subject to case management).
- Emergency Medical Transport:
  - South Africa: No annual limit with Netcare 911.
  - International: R9,010,000 per beneficiary per 90-day journey, including emergency optometry, dentistry, and terrorism cover (co-payment applies).
Key Procedures and Treatments (No Annual Limit):
- Trauma Care: Expenses for treatment following traumatic events (e.g., drowning, poisoning, severe injuries).
- Dialysis and Oncology: No limit on renal dialysis and oncology treatments.
- Organ Transplants:
  - Full coverage for transplant recipients.
  - Donor coverage: R27,500 for cadaver costs; R56,000 for live donor costs.

III. Chronic and Day-to-Day Benefits

Chronic Coverage:
- Provider: Any provider, supported by a comprehensive formulary.
- Chronic Conditions Covered:
  - 62 conditions, including 26 Prescribed Minimum Benefits (PMB), with no annual limit.
  - 36 additional conditions, subject to the R33,000 annual day-to-day limit.
- Registration Requirement: Members must register and obtain approval for chronic benefits through the Chronic Management Program.
Day-to-Day Coverage:
- Provider: Any provider
- Limit: R33,000 per beneficiary per year (combined for both day-to-day and chronic conditions).
- Sub-limits: Specific sub-limits apply annually, adjusted pro-rata for late enrollment.

IV. Health Platform Benefit

Promotes wellness and preventative care.
Components:
- Preventive Care: Screening tests and early detection.
- Maternity Program: Comprehensive maternity support.
- Health Education and Advice: Access to health resources and consultations.
Preventive Care Details:
- Immunizations and Vaccines: Baby immunizations, flu vaccines, tetanus diphtheria injection, pneumococcal vaccine.
- Early Detection Tests: Preventative dental care (R380 per beneficiary, once per year), pap smear consultation and pathologist test, HPV PCR screening test, mammogram, DEXA bone density scan, general physical examination, prostate-specific antigen test, health assessment, cholesterol test (if total cholesterol is 6 mmol/L or higher, once per year), blood sugar test (if blood sugar is 11 mmol/L or higher, once per year), glaucoma test, HIV test.
Maternity Care Benefits:
- Doula Benefit: 2 visits per pregnancy.
- Antenatal Visits: 12 visits.
- Online Antenatal and Postnatal Classes: 18-month subscription.
- Online Video Consultations with Lactation Specialists: Initial and follow-up consultations.
- Nurse Home Visits: 3 visits.
- Urine Tests (Dipstick): Included in antenatal visits.
- Pathology Tests for Maternity: Antiglobin, blood group, creatinine, full blood count, platelet count, Rhesus factor, and Rubella antibody (1 test).
- Glucose Strip and Hemoglobin Estimation: 2 tests.
- Urinalysis: 12 tests.
- Urine Tests (Microscopic Exams, Culture): As indicated.
- Pregnancy Scans: 2 pregnancy scans.
- Paediatrician Visits: 2 visits in the baby’s first year.
- 24-hour Emergency Health Advice: As needed.

V. General Healthcare Services (Day-to-Day Benefits)

Acupuncture, Homeopathy, Naturopathy, and Related Therapies: Up to R9,420 per family; subject to the overall R33,000 day-to-day limit.
- Includes: Acupuncture, homeopathy, naturopathy, herbology, audiology, occupational therapy, speech therapy, chiropractors, dieticians, biokinetics, orthoptists, osteopathy, audiometry, chiropody, physiotherapy, and podiatry.
Mental Health (Psychiatry and Psychology): R28,300 per family; subject to the overall R33,000 annual day-to-day limit.
Dentistry:
- Basic Dentistry (Extractions, Fillings): Subject to the overall R33,000 annual day-to-day limit.
- Specialized Dentistry (Bridges, Crowns): R19,800 per beneficiary, R47,700 per family; subject to the overall R33,000 annual day-to-day limit.
- Impacted Wisdom Teeth Extraction: Covered under the Major Medical Benefit at 100% of the Momentum Medical Scheme Rate; pre-authorization required.
External Medical and Surgical Appliances: R38,400 per family, with a sub-limit of R22,200 for hearing aids; subject to the overall R33,000 annual day-to-day limit.
General Practitioners and Specialists: Subject to the overall R33,000 annual day-to-day limit.
Optical and Optometry: R5,800 per beneficiary; sub-limit of R2,950 for frames; subject to the overall R33,000 annual day-to-day limit.
Pathology and Radiology: Subject to the overall R33,000 annual day-to-day limit.
Advanced Scans: MRI, CT, MRCP, whole body radioisotope, and PET scans. R2,900 co-payment per scan; pre-authorization required; covered under Major Medical Benefit.
Prescribed Medication: R25,700 per beneficiary, R42,300 per family; subject to the overall R33,000 annual day-to-day limit. Over-the-counter medication (including prescribed vitamins and homeopathic medicine) is not covered.

General Access:

All Health Platform Benefits are accessible.
Pre-notification is required for:
- Preventative dental care.
- Pap smears.
- General physical examinations.
- HIV tests.
Pre-notification can be managed via the Momentum App, web chat, Momentum website, WhatsApp, or by calling 0860 11 78 59.

Preventative Care Benefits:

Baby Immunizations:
- Coverage: Children up to 6 years old, as per Department of Health guidelines.
- Coverage across all options.
Flu Vaccines:
- Coverage: Available for children (6 months to 5 years), beneficiaries aged 60 and older, and high-risk individuals.
- Applicable to: All options.
Tetanus Diphtheria Injection:
- Coverage: Available as needed.
- Applicable to: All options.
Pneumococcal Vaccine:
- Eligibility: Beneficiaries aged 60 and older, and high-risk individuals.
- Frequency: Once a year.
- Applicable to: Summit option.
Preventative Dental Care:
- Coverage: Up to R380 per beneficiary at dentists, dental therapists, or oral hygienists.
- Frequency: Once a year.
- Applicable to: All options.
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).
- Applicable to: All options.
Mammogram:
- Eligibility: Women aged 38 and older.
- Frequency: Every two years.
- Applicable to: Summit option.
DEXA Bone Density Scan:
- Eligibility: Beneficiaries aged 50 and older.
- Frequency: Once every three years.
- Applicable to: Summit option.
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.
- Applicable to: All options.
Prostate Specific Antigen (Pathologist):
- Eligibility: Men aged 40 and older.
- Frequency: Based on age.
- Applicable to: All options.
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.
- Applicable to: All options.
Cholesterol and Blood Sugar Tests (Pathologist):
- Frequency: Once a year for principal members and adult beneficiaries.
- Applicable to: All options.
Glaucoma Test:
- Eligibility: Beneficiaries aged 40 to 49 (every two years), and 50 and older (annually).
- Applicable to: Summit option.
HIV Test (Pathologist):
- Eligibility: Beneficiaries aged 15 and older.
- Frequency: Once every five years.
- Applicable to: All options.

Maternity Programme:

Registration:
- Women must register between 8 to 20 weeks of pregnancy to access the maternity program.
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.

Health Line:

Availability: A 24-hour emergency health advice line is available to all beneficiaries across all options.

Doula Benefits

Eligibility: The Doula Benefit is available for members enrolled in the Summit option.
Pre-Delivery Consultation (Antenatal Consultation):
- Benefit: One pre-delivery consultation with the doula.
- Value: R2,400
- Tariff Code: 966072 (recommended for billing)
Post-Delivery Consultation:
- Benefit: One post-delivery consultation to address any concerns and provide support.
- Value: R2,400
- Tariff Code: 966073 (recommended for billing)
Activation: The Doula Benefit is activated once you register for the Maternity Management Programme.
Registration Timing: Registration must be done between the 8th and 20th weeks of pregnancy to ensure access to the benefit.
Contact Information:
- Momentum App: Download for easy access to services.
- Webchat: Available on momentummedicalscheme.co.za.
- Email: Send inquiries to reauthorisation@momentumhealth.co.za.
- WhatsApp: Message +27 860 11 78 59.
- Phone: Call 0860 11 78 59.

Co-payments:

Hospital Admissions: No co-payment.
In-Hospital Dentistry: No co-payment.
Extraction of Impacted Wisdom Teeth: Not covered.
MRI and CT Scans: R2,900 per scan.
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.
Key Notes:
- Members must check their option details to determine which co-payments apply.
- Momentum Medical Scheme members can also access additional products offered by Momentum Group, but these are not medical scheme benefits.
Contact Information:
- WhatsApp: 0860 11 78 59
- Web Chat: momentummedicalscheme.co.za
- Email: member@momentumhealth.co.za
- Phone: 0860 11 78 59

General Maternity Program Information:

Registration:
- Registration can be done from the 8th week of pregnancy.
- Methods: Momentum App, momentummedicalscheme.co.za, WhatsApp, or phone (0860 11 78 59).
- Required information: Email address, healthcare provider details, medical history, and expected delivery date.
BabyYumYum Partnership:
- Access to the MyMomentum BabyYumYum portal for parenting information.
- Consent is required for enrollment.

Summit Option Specific Benefits:

Antenatal Visits:
- 12 visits at a gynecologist, GP, or midwife.
- Urine dipstick tests included.
Scans:
- 2 pregnancy scans.
- 3D and 4D scans covered at the rate of 2D scans (tariff codes 3615 and 3617).
Pathology Tests:
- Coverage for:
  - Antiglobin (3709)
  - Blood group (3764)
  - Creatinine (4032)
  - Full blood count (3755)
  - Platelet count (3797)
  - Rhesus factor (3765)
  - Rubella antibody (3948)
  - Glucose strip tests (4050) (2x)
  - Hemoglobin estimations(3762) (2x)
  - Urinalysis (4188) (up to 12 tests)
  - Urine tests (microscopic exams, antibiotic susceptibility, cultures) (if requested by Doctor)
- Each of the first listed tests are covered once per pregnancy.
Maternity Coaches:
- Telephonic support for pregnancy, confinement, postnatal care, and newborn issues.
- Regular contact for high-risk pregnancies.
Doula Benefit:
- 2 doula visits (DOSA or WOMBS accredited, gynecologist must be an Associated Specialist, natural birth plan required).
- Doula benefit must be authorized during maternity benefit registration.
Baby Immunizations:
- Coverage for children up to 6 years, as per the Department of Health schedule.
- Seperate pre-authorization is required after the baby is born.
Paediatrician Visits:
- 2 visits in the baby's first year.
BellyBabies Benefit:
- Online antenatal and postnatal video classes (18-month subscription - 88420).
- Initial and follow-up video consultations with a lactation specialist (88001 and 88006).
- Discount on BellyBabies services.
- HealthSaver+ can be used for payment.
Nurse Home Visits:
- Visit the day after returning from the hospital.
- Additional visit two weeks later.
- Additional visit at 6 weeks after birth.
Family Meal Voucher:
- Voucher for a family meal delivered on the first night home.
Designer Baby Bag:
- Baby bag with essentials for mother and baby.
Hello Doctor+:
- 24/7 access to doctors via phone or text.
- Access via Momentum App, momentummedicalscheme.co.za, or the Hello Doctor app.
Associated Specialists:
- Access to gynecologists, pediatricians, and anesthetists with negotiated rates.
- Specialist locator via Momentum App or momentummedicalscheme.co.za.
Authorization for Confinement:
- Pre-authorization required within 30 days of expected delivery.
- Contact: preauthorisation@momentumhealth.co.za, WhatsApp, or phone (0860 11 78 59).
- Notify of admission date changes within 48 hours.
Adding Baby to Membership:
- Newborn registration form required.
- First month's contribution waived if registered within 30 days (and employer approved, if applicable).
Contact Information:
- Web chat: momentummedicalscheme.co.za.
- Email: member@momentumhealth.co.za.
- WhatsApp: 0860 11 78 59.

General Maternity Program Information:

Registration:
- Registration from the 8th week of pregnancy.
- Methods: Momentum App, momentummedicalscheme.co.za, WhatsApp, or phone (0860 11 78 59).
- Required information: Email address, healthcare provider details, medical history, and expected delivery date.
BabyYumYum Partnership:
- Access to MyMomentum BabyYumYum portal for parenting information.
- Consent required for enrollment.

Summit Option Specific Benefits:

Antenatal Visits:
- 12 visits at a gynecologist, GP, or midwife.
- Urine dipstick tests included (tariff code 4188).
Scans:
- 2 pregnancy scans.
- 3D and 4D scans covered at the rate of 2D scans (tariff codes 3615 and 3617).
Pathology Tests:
- Coverage includes one of each test per pregnancy:
  - 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 test per pregnancy:
  - Glucose strip (4050)
  - Hemoglobin estimation (3762)
- Coverage includes twelve of the following test per pregnancy:
  - Urinalysis (4188)
- Urine tests that are covered if requested by your treating doctor:
  - Microscopic exams (3867)
  - Antibiotic susceptibility (3887)
  - Culture (3893)
Maternity Coaches:
- Telephonic support for pregnancy, childbirth, and newborn issues.
- Regular contact for high-risk pregnancies.
Doula Benefit:
- 2 doula visits (DOSA or WOMBS accredited, gynecologist must be an Associated Specialist, natural birth plan required).
- Doula benefit must be authorized during maternity benefit registration.
Baby Immunizations:
- Coverage for children up to 6 years, as per the Department of Health schedule.
- Seperate pre-authorization is required after the baby is born.
Pediatrician Visits:
- 2 visits in the baby's first year.
BellyBabies Benefit:
- Online antenatal and postnatal video classes (18-month subscription - 88420).
- Initial and follow-up video consultations with a lactation specialist (88001 and 88006).
- Discount on BellyBabies services.
- HealthSaver+ can be used for payment.
Nurse Home Visits:
- Visit the day after returning from the hospital.
- Additional visit two weeks later.
- Additional visit six weeks after the initial visit.
Family Meal Voucher:
- Voucher for a family meal delivered on the first night home.
Designer Baby Bag:
- Baby bag with essentials for mother and baby.
Hello Doctor+:
- 24/7 access to doctors via phone or text.
- Access via Momentum App, momentummedicalscheme.co.za, or the Hello Doctor app.
Associated Specialists:
- Access to gynecologists, pediatricians, and anesthetists with negotiated rates.
- Specialist locator via Momentum App or momentummedicalscheme.co.za.
Authorization for Confinement:
- Pre-authorization required within 30 days of expected delivery.
- Contact: preauthorisation@momentumhealth.co.za, WhatsApp, or phone (0860 11 78 59).
- Notify of admission date changes within 48 hours.
Adding Baby to Membership:
- Newborn registration form required.
- First month's contribution waived if registered within 30 days (and employer approved, if applicable).
Contact Information:
- Web chat: momentummedicalscheme.co.za.
- Email: member@momentumhealth.co.za.
- WhatsApp: 0860 11 78 59.

Specialised scans, including MRI, CT, MRCP and PET scans

Coverage:
- Unlimited coverage for MRI, CT, 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.
Pre-authorization:
- 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.

Doula benefit

Eligibility:
- Members enrolled in the Summit Option can access the Doula Benefit.
Benefits:
- One pre-delivery antenatal consultation valued at R2,280.
- Tariff code 966072 is recommended for billing.
- One post-delivery consultation valued at R2,280.
- Tariff code 966073 is recommended for billing.
Criteria:
- Gynecologist must be listed among Momentum Medical Scheme’s Associated Specialists.
- Must be planning a natural birth.
- Doula must have a valid practice number and be accredited by organizations like DOSA or WOMBS.
Activation:
- The Doula Benefit is activated upon registration for the Maternity Management Programme.
- Registration must occur between 8 and 20 weeks of pregnancy.
Contact Information:
- Momentum App (download for access).
- Webchat: momentummedicalscheme.co.za.
- Email: preauthorisation@momentumhealth.co.za.
- WhatsApp: +27 860 11 78 59.
- Phone: 0860 11 78 59.

Chronic benefits

Chronic Benefit Details for Summit Option:

Provider: Freedom-of-choice.
Conditions Covered: 62 conditions (26 PMB + 36 additional).
Additional Conditions: Subject to R33,300 annual limit for day-to-day cover and additional conditions.
Annual Limit: R33,300 for day-to-day cover.
Chronic Prescription: From any provider (subject to Comprehensive formulary).
Non-Formulary Medication: Co-payment for cost difference.
Chronic Medication: From any pharmacy.

Chronic Medication Registration Process for Summit Option:

Request: Treating doctor or pharmacist contacts Momentum Medical Scheme at 0860 11 78 59.
Evaluation: Chronic benefit consultant assesses and approves or declines via phone.
Required Documents: Relevant tests may be requested from the provider.
Medication: After approval, collect from any pharmacy.
Renewal: Submit renewed prescription every 6 months.

Summary of Formulary Structure for Summit Option:

Comprehensive Formulary: Applies to Summit.
- Preferred Products: No co-payment, no reference price.
- Non-Preferred Products: No co-payment.

FAQs:

What is a Formulary?
- Formulary: A list of medications covered under your specific plan, prescribed by your doctor for chronic conditions.
What is the Momentum Medical Scheme Reference Price?
- Reference Price: The maximum amount reimbursed by Momentum Medical Scheme for a medication. Co-payments may apply if medication exceeds this price.

Clinical Registration Criteria:

The general clinical registration criteria as listed in the main document applies to the summit option, including the need for a specialist for addison's disease, and cardiac failure, and the need of lab results for chronic renal disease.

Oncology Benefit Details for Summit Option:

Annual Limit: No annual limit.
Conditions: Follows the same guidelines as other options (which are SAOC/ICON guidelines).
Providers: Any SAOC provider and pharmacy.

Accessing Oncology Benefits:

Step 1: Consult with a Qualified Oncologist or Hematologist:
- Ensure the oncologist or hematologist is a SAOC registered provider.
Step 2: Treatment Plan Submission:
- Your healthcare provider will create a treatment plan and submit it for pre-authorization.
Step 3: Documentation Submission:
- Your doctor must send the following to the Oncology Team:
  - Histology, pathology, and/or radiology reports.
  - Treatment plan with the necessary ICD-10 codes.
Step 4: Review Process:
- The Oncology Team will review your request and may reach out for additional information.
Step 5: Response Time:
- Expect a response within 2 to 3 working days regarding the approval of your treatment plan.

Treatment Types:

Active Treatment:
- Includes chemotherapy, radiotherapy, and necessary materials, all requiring pre-authorization.
Non-Active Treatment:
- Follow-up care and hormonal therapy are covered post-initial treatment, subject to pre-authorization.

Exclusions from Oncology Benefits:

Treatments outside SAOC/ICON guidelines.
Certain medications.
Reconstruction surgery.

How to Avoid Co-Payments:

Use network providers (SAOC registered providers).
Request generic medications.
Ensure correct ICD-10 codes on claims.

Prescribed Minimum Benefit Qualification:

Not all treatments qualify under Prescribed Minimum Benefits.
Coverage is available for non-Prescribed Minimum treatments.

Contact Us:

Phone: 0860 11 78 59
Email: oncology@momentumhealth.co.za
Website: Visit our website.

Support Centers:

Cancer Association of South Africa (CANSA)
People Living With Cancer (PLWC)
Reach for a Dream
The Sunflower Fund

Specialised procedures/treatment

Pre-authorization:
- Pre-authorization is mandatory for all procedures and treatments.
Anaesthetist Costs:
- Summit Option: R1,540 per procedure (pre-authorization required).
- Other Procedures: Coverage for anaesthetist costs will only apply if deemed clinically appropriate.
Co-payments for Specialised Procedures:
- Please refer to the full document for any copayments.
+HealthSaver Product:
- The +HealthSaver product is an optional complementary product available to members of the Momentum Medical Scheme.
- Note: Momentum is not a medical scheme but a separate entity from the Momentum Medical Scheme. Products offered by Momentum, such as Momentum Multiply, are not covered as medical scheme benefits.
- Membership in the Momentum Medical Scheme does not require enrollment in any Momentum products.
Further Information:
- For more information on specialised procedures, visit the full guide at content.momentum.co.za.

Africa benefit:

Eligibility:
- The Africa Benefit is accessible to members who are part of the Summit Option.
Coverage:
- Covers emergency and elective hospital admissions, day procedures, and medical admissions in sub-Saharan Africa.
- Emergency medical evacuation to the nearest suitable medical facility.
- Coverage for costs of necessary medical, surgical, hospital, emergency transport, and other treatments prior to medical evacuation.
Pre-notification:
- Pre-notification is not required for the Africa Benefit.
- Authorization must be obtained from the Scheme’s provider in sub-Saharan Africa during emergencies.
Elective Treatments:
- Members pay providers directly and submit claims for reimbursement to africaclaims@momentumhealth.co.za.
- Reimbursements are deposited into South African bank accounts.
- Reimbursement is up to a global event fee (average cost in South Africa).
- Claims must be submitted within four months of service.
Emergency Treatments:
- Members contact the Scheme’s provider at +27 11 541 1263 (reverse call charges accepted) for authorization.
- Authorized claims are submitted to internationaltravel@momentumhealth.co.za.
Provider Option:
- It is recommended that members use the Any Hospital provider option.
Countries Covered:
- Angola, Benin, Botswana, Burundi, Cameroon, Comoros, DRC, Djibouti, Equatorial Guinea, Eritrea, Ethiopia, Gabon, Ghana, Guinea, Kenya, Lesotho, Liberia, Madagascar, Malawi, Mauritius, Mozambique, Nigeria, Namibia, Réunion, Rwanda, Seychelles, Sierra Leone, Swaziland, Tanzania, Togo, Uganda, Zambia, and Zimbabwe.
Contact Details (from outside South Africa):
- Member call center: +27 31 573 4008 or +27 31 573 4000.
- Non-emergency claims: africaclaims@momentumhealth.co.za.
- Medical emergencies: +27 11 541 1263 (reverse call charges accepted).
- Emergency claim submissions: internationaltravel@momentumhealth.co.za.
- Website: momentummedicalscheme.co.za.

International Emergency Travel Cover

Eligibility:

Eligible Members: Beneficiaries enrolled in the Summit Option are covered for international leisure trips lasting up to 90 days.

Coverage Limits (per beneficiary):

Summit Option: R9.01 million

Additional Coverage:

Emergency Optometry: Up to R15,500
Emergency Dental Care: Up to R15,500
Terrorism-Related Incidents: Up to R765,000
Out-Patient Co-payment: R2,180 per claim

Definitions:

Medical Expenses:
- Definition: Reasonable and customary charges for treatments needed due to an emergency while traveling internationally.
- Coverage: Includes hospital stays, surgeries, and prescribed treatments.
Optical Expenses:
- Coverage: Emergency optical treatments up to R15,500, provided by a registered optometrist or ophthalmic surgeon.
Dental Expenses:
- Coverage: Emergency dental treatments up to R15,500, provided by a registered dentist.
What Constitutes an Emergency Condition?
- An emergency condition is a sudden and unexpected illness or injury during an insured journey requiring immediate medical or surgical treatment to prevent serious health consequences.

Coverage Period:

Start: Coverage begins when you leave South Africa.
End: Coverage lasts for 90 consecutive days or until your return to South Africa, whichever comes first.

Pre-Notification Requirements:

Mandatory Pre-Notification: All members must pre-notify Momentum Medical Scheme before traveling internationally to activate the International Emergency Travel benefit.
Fit-to-Travel Confirmation: Required from your South African doctor if:
- You’ve been hospitalized in the past two months.
- You have certain health conditions (e.g., diabetes, hypertension, cardiovascular issues).
- You are over 70 years old, pregnant, or have specific chronic conditions (e.g., respiratory diseases).
Exclusions: Active oncology treatment, chronic renal dialysis, and certain maternity-related treatments will not be covered, even with a fit-to-travel confirmation.

Pre-Notification Process:

How to Pre-Notify:
- Momentum App
- Web Chat: momentummedicalscheme.co.za
- Email: member@momentumhealth.co.za
- WhatsApp: Available for contact
- Phone: Call 0860 11 78 59
Required Information:
- Membership Number
- ID/Passport Numbers for all travelers
- Travel Dates (departure and return)
- Countries Visited and travel purpose
Travel Certificate:
- Upon pre-notification, you will receive a Travel Certificate and embassy letter (if traveling to Schengen countries for visa purposes). The certificate can also be downloaded from the Momentum App.

Consequences of Not Pre-Notifying:

Failure to pre-notify before leaving South Africa will result in loss of coverage. You will not have access to the emergency travel cover for any medical issues while abroad.

What to Do in Case of Emergency Treatment Abroad:

Call the Scheme’s Emergency Helpline: +27(0)11 541 1263 (reverse charges accepted)
Pre-Authorization: Obtain pre-authorization for treatment.
Treatment Coordination: The helpline will arrange necessary emergency transport and directly settle medical expenses with service providers.
Reimbursement: For expenses paid upfront, submit claims along with supporting documentation and authorization details to internationaltravel@momentumhealth.co.za. Ensure to include the R2,180 co-payment for each out-patient claim.
Note:
- Claims will not be covered if the emergency assistance helpline is not contacted for authorization.

Co-Payments:

In-Hospital Treatment: No co-payment required.
Out-Patient Emergency: R2,180 co-payment per claim.
- Pay upfront and submit a claim for reimbursement upon returning to South Africa.
- Claims are subject to your Day-to-Day Benefits and may be reimbursed after deducting the co-payment.

General Exclusions:

Momentum Medical Scheme will not cover expenses arising from the following:
- Pre-existing conditions not disclosed during membership application.
- Costs exceeding the annual maximum limits outlined in the Scheme Rules.
- Injuries or conditions resulting from:
  - Participation in riots, civil commotion, war, terrorism, or rebellion.
  - Professional speed contests or trials.
- Treatments not medically necessary, including cosmetic procedures, obesity-related expenses, and infertility treatments.
- Costs associated with scuba diving beyond 40 meters, cave diving, and other extreme sports.
- Maternity care or oncology treatments while traveling.
- Organ transplant-related expenses.
- Any treatment if you were traveling against medical advice or for a terminal condition.

For more information or assistance, please contact Momentum Medical Scheme via the Momentum App, email, or call the provided contact numbers.

Mental health:

General Mental Health Benefit Rules:

Benefits are accessible through Designated Service Providers, in alignment with your benefit option.
Pre-authorization is a prerequisite for both inpatient and outpatient benefits.
A treatment plan from your treating physician will be necessary.
Services such as educational assessments, disability evaluations, forensic investigations, and marriage counseling are not included within the mental health benefit framework.

Bipolar Affective Disorder (26 Chronic Disease List PMB):

Medication - Benefits are available from any provider.
Doctors, pathology, and radiology - Subject to the treatment plan.

Schizophrenia (26 Chronic Disease List PMB):

Medication - Benefits are available from any provider.
Doctors, pathology, and radiology - Subject to the treatment plan.

Depression, Acute Stress Disorder, Alcohol and Drug Rehabilitation (271 PMBs):

Medication - Covered from the chronic benefit (which accumulates to an overall day-to-day limit of R31,300 per beneficiary per year).
In-hospital - 21 days at a private facility DSP, subject to a mental health limit of R46,000 per beneficiary. Alcohol and drug rehabilitation is included within this 21-day limit (it is required to complete the full 21 days at a SANCA facility). Alternatively,
Out-of-hospital - 15 outpatient psychotherapy consultations (this is not in addition to the in-hospital benefit and limit).

Eligibility:

Individuals who have received a diagnosis of a mental health condition from their family doctor, specialist psychiatrist, or psychologist are eligible to access mental health benefits.

How to Register:

First, obtain a treatment plan from your treating physician and/or facility.
If hospitalization is necessary, you must request pre-authorisation. This can be done by emailing us at preauthorisation@momentumhealth.co.za, sending us a WhatsApp message, or calling us at 0860 11 78 59. When making this request, please include the following details in a letter of motivation from your treating physician:
- The diagnosis along with the ICD-10 code;
- The current clinical condition;
- The estimated length of stay if you are being admitted to a facility;
- The completed assessment or DSM form (diagnostic assessment and treatment plan report);
- The treatment plan, which should detail the duration of treatment and tariff codes for all healthcare providers involved, such as psychologists and psychiatrists. For children under the age of 14, a referral letter from the child’s general practitioner, pediatrician, or psychiatrist is required.
Submit a letter of motivation or completed DSM form from your treating physician for in-hospital benefits related to depression, substance abuse rehabilitation, and acute stress disorder to us via email at mmsa-communitycare@momentum.co.za for evaluation.
For outpatient psychotherapy sessions (for Prescribed Minimum Benefit conditions) instead of hospitalization, you should submit a letter of motivation or treatment plan from the treating psychiatrist or psychologist to us via email at behavioural-science@momentum.co.za.
Registration for mental health chronic benefits (specifically for bipolar affective disorder and schizophrenia) must be initiated by the treating psychiatrist through the chronic registration process. For chronic medication registration, please contact 0860 11 78 59. Once your registration is authorized, ensure that you obtain your chronic medication on a monthly basis and adhere strictly to the prescribed dosage and quantity. It is crucial not to miss any doses, as non-compliance can have serious repercussions for your health and overall well-being.

Glossary of terms used in this document:

Chronic Disease List (CDL)
Designated service provider (DSP)
DSM form
ICD-10 code
Prescribed Minimum Benefits (PMBs)
Tariff codes
HealthSaver+

Specialised procedures/treatment

Pre-authorization:
- Pre-authorization is mandatory for all procedures and treatments, regardless of location.
Anaesthetist Costs:
- Summit Option: R1,460 for procedures like gastroscopies and colonoscopies, provided pre-authorization is obtained.
- Other Procedures: Coverage for anaesthetist costs will only apply if deemed clinically appropriate.
Co-payments for Specialised Procedures:
- The document indicates that some specialised procedures and treatments may result in co-payments. For the specific co-payment amounts, it directs the user to the provided document.
HealthSaver Product:
- HealthSaver is offered as a complementary product.
- Momentum is not a medical scheme and operates separately from Momentum Medical Scheme.
- Complementary products are not medical scheme benefits.
- Membership in Momentum Medical Scheme does not require enrollment in complementary products.

Trauma benefit:

Availability:
- The Trauma Benefit is available under the Summit plan.
Eligible Conditions for Coverage:
- Severe Burns: Coverage is available if the severity of the burns meets specific criteria, and coverage is contingent upon the FIMS score (Functional Independence Measure Scale).
- Paraplegia and Quadriplegia: Coverage is available if the individual experiences paraplegia or quadriplegia, and coverage is contingent upon the FIMS score.
- Post-Traumatic Stress Disorder (PTSD): Coverage is available for PTSD arising from a serious reported crime. A valid case number from the police report is required.
- Additional Conditions (with ICU Stay): Coverage is available if the individual has had an ICU stay of 5 days or longer due to:
  - Near drowning
  - Poisoning
  - Severe allergic reactions
  - Head injuries (external and internal)
How to Access the Trauma Benefit:
- Step 1: Hospital Admission: Members must first be admitted for the traumatic event. Pre-authorization is required as per emergency protocols.
- Step 2: Authorization for Follow-Up Care: The treating physician must contact the Scheme to obtain authorization for follow-up care. A comprehensive treatment plan is required, detailing the treatments needed, such as:
  - Wound care for burns
  - Nursing services
  - GP and specialist visits
  - Radiology and pathology services
Contact Information:
- Web chat: Available on momentummedicalscheme.co.za.
- Email: Send inquiries to member@momentumhealth.co.za.
- WhatsApp: Message +27 860 11 78 59.
- Phone: Call 0860 11 78 59.

Availability:
- The Trauma Benefit is available under the Summit Option.
Covered Conditions:
- Severe burns (must meet qualifying criteria and FIMS score).
- Paraplegia and quadriplegia (contingent upon FIMS score).
- Post-traumatic stress disorder (PTSD) from serious reported crimes (requires police case number).
- Conditions resulting from ICU stay of five days or more due to:
  - Near drowning.
  - Poisoning.
  - Severe allergic reactions.
  - External and internal head injuries.
Accessing the Benefit:
- Hospital admission for the traumatic event must be pre-authorized.
- Treating physician must contact the Scheme to authorize follow-up care.
- Physician must provide a comprehensive treatment plan, including:
  - Wound care for burns.
  - Nursing services.
  - GP and specialist visits.
  - 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.
FIMS:
- FIMS refers to the Functional Independent Measure Scale, which evaluates an individual's capacity to engage in daily living activities.

Coverage:
- Beneficiaries enrolled in the Summit Option are entitled to coverage for a leisure journey lasting up to 90 days.
- Coverage Limit: R9.01 million per beneficiary.
- The total coverage limit includes R15,500 for emergency optometry, R15,500 for emergency dental services, and R765,000 specifically for terrorism-related incidents.
- A co-payment of R2,070 is applicable for each out-patient claim.
Definitions:
- Medical expenses: Reasonable and customary charges for emergency treatments during international trips.
- Optical expenses: Emergency optical treatments up to R15,500 by registered optometrists or ophthalmic surgeons.
- Dental expenses: Emergency dental treatments up to R15,500 by registered dentists.
- Emergency condition: Sudden and unexpected illness or injury requiring immediate medical treatment.
Period of Cover:
- Coverage begins upon leaving South Africa and lasts for 90 consecutive days or until return, whichever is first.
Pre-Notification:
- Mandatory pre-notification to Momentum Medical Scheme before international travel.
- Fit-to-travel questionnaire required from South African doctor if:
  - Hospitalized in the past two months.
  - Registered in health management programs.
  - 60 years or older.
  - Pregnant.
  - Underlying conditions (diabetes, hypertension, cardiovascular issues).
  - Immune-suppressive condition.
  - Chronic respiratory diseases or conditions.
- Exclusions: Active oncology treatment, home oxygen dependence, chronic renal dialysis, maternity benefits.
- Fit-to-travel confirmation 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 information: Membership number, ID/passport numbers, travel dates, countries visited, travel purpose.
- Travel Certificate and embassy letters provided upon pre-notification.
Failure to Pre-Notify:
- Loss of international emergency travel cover benefits.
Emergency Treatment Abroad:
- Contact emergency helpline: +27(0)11 541 1263 (reverse charges accepted) for pre-authorization.
- Helpline coordinates emergency transport.
- Direct settlement of medical expenses with service providers.
- Reimbursement: Submit claims with documentation and authorization details to internationaltravel@momentumhealth.co.za (R2,070 co-payment applies to out patient claims).
- Claims not covered without helpline authorization.
- Day to day claims must be submitted within one month of returning to south africa.
Co-Payments:
- No co-payment for in-hospital treatment.
- R2,070 co-payment per claim for out-patient emergency medical expenses.
- Healthsaver funds can be used to cover shortfalls.
General Exclusions:
- Pre-existing conditions not disclosed.
- Costs exceeding annual maximums.
- Injuries from riots, wars, terrorism.
- Professional speed contests.
- Unregistered healthcare providers.
- Recuperative holidays.
- Treatments with unsubstantiated efficacy.
- Cosmetic procedures.
- Obesity treatments.
- Attempted suicide (beyond limited coverage).
- Breast reduction/augmentation, gynecomastia, otoplasty, blepharoplasty.
- Unregistered medications.
- Unregistered institutions.
- Gum guards, gold dentures.
- Frail care.
- Non-emergency travel expenses.
- Non-medically necessary treatments.
- Missed appointments.
- Circumcision (unless clinically indicated), contraception.
- Vasectomy/tubal ligation reversal.
- Substance abuse injuries.
- Infertility treatments.
- Scuba diving (beyond 40m), cave diving.
- Maternity care during travel.
- Oncology care during travel.
- Organ transplants.
- Chronic renal failure.
- Injuries during waiting periods.
- Travel against medical advice.
- Failure to obtain a fit to fly confirmation.

HIV/Aids Management Programme:
- Momentum Medical Scheme provides comprehensive management and treatment for individuals living with HIV/Aids.
- The objective is to ensure access to suitable medical care that promotes wellness, prevention, and ongoing support.
- Members must enroll in the Lifesense HIV programme to access HIV/Aids treatment benefits.
Registration:
- Anyone with a positive HIV test result must enroll promptly.
- Pregnant members are strongly encouraged to register immediately.
- Registration is confidential.
- Member or treating physician contacts Lifesense.
- Lifesense collaborates with healthcare providers for a treatment plan.
- Includes education, support, and access to ARV medication.
- The Scheme manages annual benefit limits.
Post-Exposure Prophylaxis (PEP) Treatment:
- Available for potential HIV exposure (needle stick injury, sexual assault).
- Contact Lifesense to access PEP treatment.
Where to get anti-retroviral medication:
- Summit Option: Members can acquire their medication from any provider of their choice.
Lifesense Contact Details:
- Tel: 0860 50 60 80
- Fax: 0860 80 49 60

Major Medical Benefits:
- Sub-limits for in-hospital benefits increased.
- Co-payments for specialized scans will increase.
Chronic Benefits:
- Coverage for 62 chronic conditions, including CDL conditions.
- Chronic condition medication can be obtained from any provider adhering to the formulary.
- Annual limit for 36 additional chronic conditions increased to R33,000 per beneficiary.
Day-to-Day Benefits:
- Annual day-to-day limit increased to R33,000 per beneficiary.
- Increased sub-limits for dentistry and optometry within the day-to-day cover.
Health Platform Benefits:
- Free early detection and preventative care benefits continue.
- Dental benefit increased to R380 per beneficiary.
- International emergency benefit co-payment increased to R2,180 per outpatient claim.

Multiply Inspire and Inspire Plus:
- Members of the Momentum Medical Scheme enrolled in the Summit Option will continue to enjoy complimentary access to Multiply Inspire.
- Multiply Inspire offers:
  - Personalized Lifestyle Score and Digital Coach Tool.
  - Base level HealthReturns.
  - Base level partner rewards.
- Upgrade to Multiply Inspire Plus for:
  - 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 for Multiply Inspire Plus members:
- Summit Option members with Multiply Inspire Plus can earn up to R1,500 in HealthReturns per adult monthly.
- Earning activities include:
  - Health assessments and digital screenings.
  - Fitness assessments and digital screenings.
  - Achieving Weekly and Monthly Wins (Active Dayz goals).
  - Meeting weekly and monthly Recharge Goals (sleep quality, readiness).
  - Participating in leaderboard challenges.
Multiply Premier changes:
- Summit Option members will be automatically transitioned to Multiply Inspire Plus in January 2024.
- HealthReturns will only be accessible through Multiply Inspire and Inspire Plus moving forward.
Momentum GapCover:
- The shortfall benefit will increase from R185,000 to R190,000 per insured person annually.
- The casualty benefit will see an increase from R22,000 to R23,000 per policy each calendar year. Additionally, the coverage for emergency-only casualty ward visits will rise from R3,500 to R4,000, and the age limit for emergency-only visits for child dependants will expand from six to seven years.
- The internal prosthesis shortfall benefit will increase from R30,000 to R35,000 per policy annually. Stents and pacemakers will now be covered up to a new sub-limit of R8,000 per claim event, aggregating to the total R35,000 benefit per policy per year.
- The baby bump benefit will increase from R2,000 to R2,500.
- The Cancer Assist Benefit will see an increase from R5,000 to R8,000 for first-time diagnoses of minimum stage 2, local, and malignant cancer.
General Information:
- Momentum’s complementary products are offered by Momentum Metropolitan Holdings Limited, which is separate from Momentum Medical Scheme.
- These products are not medical scheme benefits.
- The Healthsaver card will be used for medical purchases, and the momentum money card and app will be used for standard purchases.

Day-to-day Benefit Structure:
- Claims are reimbursed at 100% of the Momentum Medical Scheme Rate, subject to certain sub-limits.
- There is an overall day-to-day limit of R31,300 per beneficiary.
Claims Submission:
- Convenient method: Photograph the claim using a cellphone and upload it via the Momentum App.
- Email: claims@momentumhealth.co.za.
- Postal: Momentum Medical Scheme Claims, PO Box 2338, Durban, 4000.
Required Claims Information:
- Membership number.
- Principal member’s name and surname.
- Patient’s name and surname.
- Treatment date.
- Amount charged.
- Relevant ICD-10 code.
- Tariff code and/or Nappi code.
- Service provider’s name and practice number.
- Proof of payment (if applicable).

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

Costs incurred during waiting periods and for undisclosed pre-existing conditions.
Costs exceeding annual maximum limits (Annexure B of Scheme Rules).
Injuries or conditions from riots, civil disturbances, warfare, invasions, terrorist acts, or rebellions.
Expenses related to professional speed contests or trials.
Services from unregistered healthcare providers.
Costs of recuperative holidays.
Costs of treatments with unsubstantiated efficacy and safety.
Cosmetic procedures not linked to a medical condition.
Obesity treatments.
Suicide attempt expenses (beyond limited coverage).
Breast reduction, breast augmentation, gynaecomastia, otoplasty, and blepharoplasty.
Medication not registered with the Medicine Control Council.
Services from unregistered institutions/nursing homes (except state facilities).
Gum guards and gold used in dentures.
Frail care services.
Non-emergency travel expenses.
Non-medically necessary treatments.
Missed appointments.
Circumcision (unless clinically indicated), contraceptive measures or devices.
Reversals of vasectomies or tubal ligations.
Injuries from substance abuse (except Prescribed Minimum Benefits).
Infertility treatments (if Prescribed Minimum Benefits, covered in state facilities under specific conditions).
Injuries from scuba diving (depths >40 meters) or cave diving.

Additional Exclusions for International Emergency Travel Cover (Summit Option Specific):

Care or treatment related to maternity (including emergencies) during travel.
Oncology care or treatment during travel.
Organ transplant-related care or treatment.
Care related to chronic renal failure.
Injuries, illnesses, or emergency conditions during waiting periods.
Travel against medical advice or with a pre-existing terminal condition.
Failure to meet fit-to-fly questionnaire criteria.

6.1 Out-of-Hospital Basic Dentistry (Extractions, Fillings):
- Limit: R31,300 per beneficiary per year (overall day-to-day limit).
6.2 Out-of-Hospital Specialized Dentistry (Bridges, Crowns):
- Limit: R18,800 per beneficiary, R45,300 per family (within R31,300 overall day-to-day limit).
- 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).
  - Requirement: Pre-authorization.
6.3 In-Hospital Dental and Oral Benefits:
- Maxillo-facial Surgery (Excluding Implants) and General Anaesthesia (Children under 7):
  - Anaesthetist: 300% of Momentum Medical Scheme Rate.
  - Hospital: Full at negotiated rate.
  - Dental, Specialist, Maxillo-facial Surgeon: Day-to-day Benefits, within R31,300 limit.
- Dentistry Related to Trauma:
  - Hospital: Full at negotiated rate.
  - Anaesthetist, Dentist

Available Benefits:
- Summit Option: Provides R68,000 per family for medical rehabilitation, private nursing, hospice, and step-down facilities, subject to case management.
General Information:
- Physical rehabilitation is a therapeutic program to regain strength, mobility, and independence after illness, injury, surgery, or accidents.
- Rehabilitation can occur at home or in step-down facilities.
- Covered treatments and services include:
  - Step-down facilities
  - Occupational therapy
  - Speech therapy
  - Physiotherapy
  - Wound care
  - Stoma care
  - Home nursing
  - Social workers
- A disability is a condition that hinders daily activities (physical, cognitive, mental, sensory, emotional, developmental).
- Physical rehabilitation aims to restore physical strength and functionality through a team of specialists.
- Eligibility: Members with significant life-altering events or injuries requiring hospitalization, with a treating doctor's discharge plan.
- The discharge plan includes follow-up visits, investigations, medications, medical devices, rehabilitation plan, and step-down facility/hospice transfer.
- Home environment evaluation may be part of the rehabilitation plan.
- A case manager from Momentum Medical Scheme monitors recovery.
- Medical schemes cannot provide unlimited rehabilitation funding.
- Coverage ceases when no further functional benefit is expected or skills are transferred to a caregiver.
- Frail care is excluded.
How to register for treatment in a step-down facility:
- A letter of motivation from the treating doctor is required, including:
  - Diagnosis and ICD-10 code.
  - Current clinical condition.
  - Estimated length of stay (if transferring).
  - Facility assessment with a valid practice number.
  - Treatment plan with service tariff codes.
- The doctor or hospital case manager emails the letter to subacute@momentum.co.za.
- Case manager evaluation based on clinical protocols and evidence-based medicine.
- Response within 48 hours.
- Appeals: email subacute@momentum.co.za.
How to register for home nursing or Hospice:
- A letter of motivation from the treating doctor is required, including:
  - Diagnosis and ICD-10 code.
  - Current clinical condition.
  - Estimated duration of service.
  - Facility assessment with a valid practice number.
  - Treatment plan with service tariff codes.
- Response to the doctor or nursing agency within 48 hours.
- Appeals: email subacute@momentum.co.za.
How to register for wound care:
- A letter of motivation from the treating doctor is required, including:
  - Diagnosis and ICD-10 code.
  - Dated, color photographs of the wound.
  - Estimated dates for wound care.
  - Nursing sister's valid practice number.
  - Wound care tariff codes.
  - List of required items and dressings.
- Response within 48 hours.
- Appeals: email subacute@momentum.co.za.
- Updated progress reports from the treating providers must be submitted weekly.

Benefit Limits:
- Summit: This option is distinctive in that it does not impose an annual limit on benefits. The same pricing guidelines apply, with sub-limits for specialized oncology treatments as previously mentioned, offering unparalleled access to care.
Your benefit option and chronic provider determine which specialists and pharmacy you may use:
- Summit: Similar to the other options, members can select any SAOC registered oncology provider and any pharmacy for their medications, ensuring comprehensive access to necessary treatments.
Active treatment:
- Active treatment refers to the phase during which a patient undergoes chemotherapy, radiotherapy (radiation), or brachytherapy, depending on their specific diagnosis and treatment plan. All treatments are approved in accordance with the SAOC or ICON guidelines, Scheme Rules, and the design of the benefits, ensuring that members receive the care they need.
- Chemotherapy: This treatment may include adjuvant chemotherapy, which is administered to eliminate any remaining cancer cells after surgery, thereby significantly reducing the risk of recurrence. Alternatively, palliative chemotherapy may be utilized to alleviate symptoms and slow the progression of the disease. The pricing for chemotherapy and adjuvant medications follows the Momentum Medical Scheme Reference Pricing.
- Radiotherapy utilizes high-energy rays to target and destroy cancer cells. While this treatment can also affect healthy cells, it is important to note that cancer cells generally lack the ability to repair themselves, whereas healthy cells typically can recover after treatment. Palliative radiotherapy may also be employed to provide relief from symptoms.
- All materials necessary for administering active treatment, such as drips, needles, and any supportive treatments, are covered under the active treatment benefits, ensuring that patients do not face additional financial burdens.
- The comprehensive treatment plan includes consultations, infusion fees, pathology, radiology, and all medications necessary for effectively treating the disease, providing a holistic approach to cancer care.
- Consultations with the oncologist are fully covered at 100% of the Momentum Medical Scheme Rate, provided that you utilize the applicable network provider according to your benefit option, ensuring that members have access to expert care without added costs.
- Pathology tests related to your condition will be covered at 100% of the Momentum Medical Scheme Rate if they are requested by the treating network doctor and are pre-authorized, further emphasizing the importance of following the correct procedures.
- Radiology services related to your condition will also be covered at 100% of the Momentum Medical Scheme Rate if requested by the treating network doctor and pre-authorized. This coverage includes basic x-rays and scans, as well as specialized radiology services such as CT, MRI, and nuclear scans, although a co-payment may apply for specialized services. It is crucial to remember that scans not directly related to cancer will not be covered under the oncology benefit.
Non-active treatment:
- The Momentum Medical Scheme provides coverage for follow-up (non-active) treatment after the initial treatment is completed, contingent upon pre-authorization. This category of treatment includes various important services:
- Hormonal therapy, which is applicable for different cancer types, such as breast and prostate cancer, and is covered as per SAOC and ICON guidelines, ensuring that patients receive the necessary ongoing care.
- Follow-up care encompasses consultations, pathology, and radiology as previously mentioned, allowing for continuous monitoring of the patient's condition.
- Pain management is also included for patients experiencing extensive disease spread, ensuring that comfort remains a priority during treatment.
- Lymph drainage (physiotherapy) conducted by an accredited therapist is covered, provided that the complication arises as a result of radiation and axillary clearance, emphasizing the importance of comprehensive care.
- Support from registered clinical coaches is available to assist patients and their families with the necessary follow-up care, providing guidance and resources during the recovery process.
What is not covered from the oncology benefit?
- Treatments that do not fall within the parameters established by the SAOC or ICON guidelines and formularies, as well as the Scheme Rules, will not be covered. This ensures that all provided services maintain a high standard of care.
- Acute medications such as antibiotics, antidepressants, anxiety medications, sleeping tablets, vitamins, and homeopathic remedies are not covered under oncology benefits but may be claimed from available Day-to-day benefits, allowing for some flexibility in treatment options.
- External breast prostheses, specialized bras, stoma products, and oxygen therapy are covered under the Major Medical Benefit, subject to applicable limits based on your benefit option, ensuring that members receive necessary support.
- Reconstruction surgery is not included within the oncology limit but is funded through the Major Medical Benefit. In cases of breast cancer, if the mastectomy was not performed while the member was enrolled in the Momentum Medical Scheme, we will require supporting documentation to process claims.
- Hospice and home-based nursing care benefits are covered under the relevant Major Medical Benefit; however, pre-authorization is necessary in consultation with the treating oncologist. Limits will apply based on your benefit option. It is important to note that hospice and private nursing care are not covered under the Ingwe Option.
- Mental health benefits related to the impact of oncology treatment must be authorized. If approved, treatment will be covered under the mental health benefit, subject to the limits applicable to your benefit option, recognizing the emotional toll that cancer can take.
- Treatment for chronic conditions that arise as a result of medication will be subject to your chronic benefit, ensuring that ongoing health issues are addressed.
- Wigs are funded through available Day-to-day benefits, helping to alleviate some of the physical challenges associated with cancer treatment.
How to avoid co-payments:
- To minimize co-payments, it is advisable to utilize doctors and pharmacies that are part of your benefit option’s networks. Collaborating with your treating doctors will help ensure that the treatment provided aligns with the appropriate guidelines and formularies, reducing unexpected costs.
- Request that your doctor consider prescribing generic medications. While your doctor will ultimately determine the appropriateness of generic medications, this choice may influence the funding for the prescribed medicine, potentially lowering out-of-pocket expenses.
- Ensure that all treatment remains within the benefit limits set for your specific option to avoid incurring additional costs, which can add financial stress during an already challenging time.
- Make sure that the correct ICD-10 codes related to your cancer diagnosis are included on all claims submitted to us, including those for pathology and radiology. It is advisable to discuss this with your doctors to ensure they submit claims with the correct ICD-10 codes, as per the treatment plans submitted or as provided when authorized.
When does oncology qualify as a Prescribed Minimum Benefit?
- It is important to understand that not all cancer treatments are classified as Prescribed Minimum Benefit treatments. However, this does not imply that there will be no coverage for cancer treatments that do not qualify as Prescribed Minimum Benefits, as oncology benefits still apply to non-Prescribed Minimum Benefit cancer treatments, with the exception of the Ingwe Option, which only covers Prescribed Minimum Benefits.
- Once the oncology limits for cancer treatment have been exceeded, the Scheme will cover 80% of the benefit for the remainder of the year. This means that you, as the member, will be responsible for 20% of the associated costs, ensuring that you continue to receive necessary care even after reaching your limit.
Contact details:
- If you have any questions or require further information, please do not hesitate to reach out to us. We are here to help you navigate your healthcare needs during this difficult time.
- Member contact centre: 0860 11 78 59 – You can either WhatsApp or call us for assistance.
- Email: oncology@momentumhealth.co.za
- Web: momentummedicalscheme.co.za
Support centres for oncology patients:
- Cancer Association of South Africa (CANSA) - Toll-free: 0800 22 66 22 - Email: info@cansa.org.za
- People Living With Cancer (PLWC) - Toll-free: 0800 03 33 37 / 021 565 0039 - Email: info@plwc.org.za
- Reach for a Dream - Tel: 011 880 1740 - Email: info@reachforadream.org.za - Web: reachforadream.org.za
- The Sunflower Fund - Toll-free: 0800 12 10 82 - Web: sunflowerfund.org.za
Glossary of terms used in this document:
- Term
- Momentum Medical Scheme Reference Pricing: This term refers to the maximum amount that the Scheme will reimburse for a specific medication. If a medication costs more than the established reference pricing, you will be responsible for covering the difference in cost, ensuring transparency in your healthcare expenses.
- Generic medication: A generic drug is a pharmaceutical product that is equivalent to a brand-name drug in terms of dosage, strength, route of administration, quality, performance, and intended use, but does not carry the brand name. The active pharmaceutical ingredient is the same as the original, although there may be differences in manufacturing processes, color, taste, and packaging, making generics a cost-effective alternative.
- ICD-10 code: This coding system is used to document various medical records, including diseases, symptoms, abnormal findings, and external causes of injury. Essentially, it is your diagnosis code, which is crucial for accurate billing and treatment tracking.
- ICON: This stands for the Independent Clinical Oncology Network, which plays a vital role in providing standardized care across various oncology providers.
- Oncologist: An oncologist is a medical doctor who specializes in diagnosing and treating cancer, ensuring that patients receive expert care tailored to their specific needs.
- Prescribed Minimum Benefits: Prescribed Minimum Benefits (PMBs) refer to a specific list of benefits that all medical schemes in South Africa are mandated to provide coverage for, as outlined in the Medical Schemes Act 131 of 1998 and its accompanying 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 treatments specified in the defined benefits.
  - You must utilize the Scheme’s Designated Service Providers, ensuring that you receive care that meets the established standards.
  - If you choose to use non-designated service providers voluntarily, the Scheme will cover benefits up to the Momentum Medical Scheme Rate, and relevant co-payments will be applicable. In cases of emergency medical conditions where non-designated service providers are used, it is considered involuntary, and co-payments will be waived. If your medical condition and treatment do not meet the criteria for accessing these benefits, we will process claims according to the benefits available on your selected benefit option.
- SAOC: This stands for the South African Oncology Consortium, which is instrumental in establishing guidelines and protocols for oncology care.

Shortfall benefits (these benefits aggregate to a maximum of R190 000 per insured person per year)
- Benefit for shortfalls in medical practitioner costs:
  - Summit Option: 1,200% of the Momentum Medical Scheme Rate.
Co-payments
- This benefit covers any co-payments that your medical scheme applies to hospital admissions, procedures, and certain treatments performed in day clinics.
- Co-payments on oncology treatment:
  - Momentum GapCover will cover the 20% co-payment that is applied to oncology treatment once the medical scheme limit has been exceeded.
Robotic procedure shortfall benefit
- If your medical condition necessitates robotic-assisted surgery, this benefit will cover the shortfall related to the fees charged by the medical practitioners performing the procedure, up to three times the amount reimbursed by your medical scheme.
Robotic procedure co-payment benefit
- In the event that your medical scheme imposes a co-payment for robotic-assisted surgery, Momentum GapCover will cover you for up to R12,000 per policy per year.
Casualty benefit
- This benefit covers casualty fees associated with emergency room admissions at registered hospital casualty facilities due to medical emergencies or accidents. The coverage is limited to five casualty visits and up to R23,000 per policy per calendar year. Notably, three of these casualty visits may be utilized exclusively in emergencies for dependents aged seven years or younger. The emergency benefit is capped at R4,000 and will count towards your total of five claim events and the R23,000 annual benefit limit.
Internal prosthesis shortfall benefit
- This benefit covers shortfalls associated with internal prosthesis costs, up to a maximum of R35,000 per policy per year. Specific sub-limits apply, such as R8,000 per claim event for stents and pacemakers, although this is subject to the overall policy limit of R35,000.
Assist benefits (these benefits do not aggregate to the R190 000 cap)
- Cancer Assist benefit:
  - In the unfortunate event that you are diagnosed for the first time with a minimum stage 2, local and malignant cancer, we will provide you with a payment of R8,000. If you are diagnosed with minimum stage 2, regional and malignant cancer, the payout increases to R20,000. Additionally, if you receive the R20,000 benefit and your medical scheme pays over R200,000 for your oncology treatment within 12 months of your diagnosis, we will grant you a further R15,000. This benefit is available only once in a lifetime for each person covered under the policy.
- Breast reconstruction benefit for non-affected breast:
  - If you are diagnosed with breast cancer and require cosmetic breast reconstruction for the non-affected breast following a mastectomy, we will provide assistance cover of R15,000 per policy per year. This benefit can be utilized to cover costs incurred for the treatment or related expenses.
- Accident Assist benefit:
  - This benefit offers a payout of R55,000 in the event of death or permanent disability resulting from an accident. This benefit is subject to one claim per insured individual for their lifetime.
- Violent crime benefit:
  - In the event that you or a dependent successfully claims the Accident Assist benefit due to a violent crime, we will double the payout amount to R110,000.
- Premium waiver benefit:
  - If you or a dependent responsible for paying the monthly premium for this policy passes away or becomes permanently and totally disabled due to an accident while covered under this policy, we will assist your dependents by covering their monthly medical scheme contributions and gap cover premium with an upfront payment of R36,000.
- Trauma and bereavement counselling benefit:
  - If you have been a victim of or a witness to an act of violence—such as murder, assault, robbery, rape, kidnapping, or hijacking—or if you experience a traumatic accident or suffer the loss of an immediate family member, we will cover trauma counselling fees at a rate of R800 per session, limited to R30,000 per policy per year.
- Baby bump benefit:
  - If you become pregnant while covered under this policy, we will provide you with an upfront amount of R2,500 to help with any unexpected expenses that may arise.
Premiums
- The premium amounts are shown, but they are based on age, and not the medical aid option.
Waiting periods
- The waiting periods apply to all the medical aid options.
How to claim
- The claim process information applies to all medical aid options.
What we do not cover
- The excluded items apply to all medical aid options.
General exclusions
- The general exclusions apply to all medical aid options.
Terms and conditions of cover
- The terms and conditions apply to all medical aid options.

Momentum GapCover Supreme:

Shortfall benefits (these benefits aggregate to a maximum of R200,000 per insured person per year)
- Benefit for shortfalls in medical practitioner costs:
  - Summit Option: 1,200% of the Momentum Medical Scheme Rate.
Co-payments:
- This benefit addresses co-payments that your medical scheme may apply for hospital admissions, procedures, and certain day clinic treatments.
- Co-payments on oncology treatment:
  - This provision covers the 20% co-payment that is applied to oncology treatment once the medical scheme limit has been reached.
Robotic procedure shortfall benefit:
- In cases where your medical condition necessitates robotic-assisted surgery, this benefit will cover the shortfall related to the fees charged by the medical practitioners performing the surgery, up to three times the amount reimbursed by your medical scheme.
Robotic procedure co-payment benefit:
- If your medical scheme requires a co-payment for robotic-assisted surgery, this benefit will cover you up to R12,000 per policy per year.
Casualty benefit:
- Should you visit a casualty ward within 24 hours of an emergency resulting from an accident, this benefit will pay up to R24,000 for all incurred costs. This benefit is limited to five casualty visits per family per year. Furthermore, three of these visits, capped at R5,000 per policy per year, may be utilized in emergencies (regardless of whether they were accident-related) for children aged eight years or younger. The costs associated with these three visits will count towards the R24,000 annual limit.
Internal prosthesis benefit:
- This benefit covers shortfalls related to internal prosthesis costs, with a maximum coverage of R35,000 per policy per year. Stents and pacemakers are specifically covered up to a sub-limit of R8,000 per claim event, which is still subject to the overall policy limit of R35,000.
Assist benefits (these benefits do not aggregate to the R200,000 cap)
- Cancer assist benefit:
  - If you receive a first-time diagnosis of minimum stage 2, local and malignant cancer, we will provide you with a payment of R8,000. In cases where you are diagnosed with minimum stage 2, regional and malignant cancer, the payout will increase to R20,000. If, following the R20,000 benefit, your medical scheme covers more than R200,000 for your oncology treatment within 12 months of your diagnosis, we will provide an additional R15,000. This benefit is available once in a lifetime for each person covered under the policy.
- Breast reconstruction benefit for non-affected breast:
  - If you are diagnosed with breast cancer and require cosmetic breast reconstruction for the non-affected breast following a mastectomy, we will provide coverage of R15,000 per policy per year. This financial assistance can be utilized to recover costs associated with the treatment or related expenses.
- Accident assist benefit:
  - This benefit provides a payout of R55,000 in the event of death or permanent disability due to an accident. It is important to note that this is subject to a limit of one claim per insured individual per lifetime.
- Violent crime benefit:
  - If you or a dependent successfully claims the Accident Assist benefit and the claim event was a result of a violent crime, we will double the payout to R110,000, providing additional support during a difficult time.
- Premium waiver benefit:
  - In the unfortunate event that you or a dependent responsible for paying the monthly premium on this policy passes away or becomes permanently and totally disabled due to an accident while covered under this policy, we will assist your dependents by covering the cost of their monthly medical scheme contributions and gap cover premiums with an upfront payment of R36,000.
- Trauma and bereavement counselling benefit:
  - If you are a victim of or witness to an act of violence (such as murder, assault, robbery, rape, kidnapping, or hijacking), experience a traumatic accident, or suffer the loss of an immediate family member, we will pay you a fixed amount of R800 per session for trauma counselling fees, with a limit of R30,000 per policy per year.
- Baby bump benefit:
  - If you become pregnant while covered under the policy, we will provide you with an upfront payment of R2,500 to assist with any unexpected costs that may arise during your pregnancy.
Momentum GapCover Supreme premiums:
- The premiums are based on age groups, and family or single, and not the specific medical aid option.
Momentum GapCover Primary:
- Shortfall benefits (these benefits aggregate to a maximum of R200,000 per insured person per year)
  - Benefit for shortfalls in medical practitioner costs:
    - Summit Option: 1,200% of the Momentum Medical Scheme Rate.
- Co-payments:
  - This benefit addresses co-payments applied by the medical scheme for hospital admissions, procedures, and certain day clinic treatments.
- Casualty benefit:
  - If you visit a casualty ward within 24 hours of an emergency caused by an accident, we will cover up to R12,000 of all costs incurred. This benefit is limited to five casualty visits per family per year. Additionally, three of these visits, capped at R2,500 per policy per year, may be utilized in emergencies (regardless of the cause) for children aged eight years or younger. The costs associated with these three visits will count toward the R12,000 annual limit.
- Momentum GapCover Primary premiums:
  - The premiums are based on age groups, and family or single, and not the specific medical aid option.
Quotes for employer groups:
- The quotes for employer groups, and the information needed to create those quotes, are the same for all medical aid options.
Waiting periods:
- The waiting period information is the same for all medical aid options.
How to claim:
- The how to claim information is the same for all medical aid options.
Out-of-hospital/day clinic procedures we cover:
- The list of out of hospital procedures that are covered are the same for all medical aid options.
Allied professionals that we cover:
- The list of allied professionals that are covered are the same for all medical aid options.
What we do not cover:
- The list of items that are not covered are the same for all medical aid options.
General exclusions:
- The general exclusions are the same for all medical aid options.
Terms and conditions of cover:
- The terms and conditions are the same for all medical aid options.

Individual Underwriting:
- If joining as an individual, the underwriting is based on your medical history.
- This means that the information you provide on your individual application for membership is what the underwriting decision will be based on.
Waiting Periods:
- The waiting periods depend on your previous medical scheme coverage:
  - Type 1 (no previous cover or a break of more than 3 months):
    - 12-month condition-specific waiting period.
    - 3-month general waiting period.
    - Prescribed Minimum Benefits are not covered during the waiting periods.
  - Type 2 (less than 2 years of continuous cover, break of less than 3 months):
    - 12-month condition-specific waiting period for new conditions.
    - Any remaining waiting periods from the previous scheme.
    - Prescribed Minimum Benefits are covered.
  - Type 3 (more than 2 years of continuous cover, break of less than 3 months):
    - 3-month general waiting period.
    - Prescribed Minimum Benefits are covered.
- Transferring from a closed or restricted scheme with less than a three-month break in coverage means no waiting periods will be applied.
Late Joiner Penalties:
- These apply if you are 35 or older and:
  - Were not a member of a medical scheme before April 1, 2001.
  - Have had a break of more than 3 months in membership since April 1, 2001.
- Penalties range from 5% to 75% depending on the years of non-coverage.
Examples:
- The provided examples, while not mentioning the summit option, show how the waiting periods and late joiner penalties are applied in various situations, and those same applications would be used for a person joining the summit option.
Application Forms:
- Individual applications for membership are required for all individual members and for all members of compulsory groups.
- Super group application forms and health import templates are required for super groups.

Momentum GapCover:
- Momentum GapCover has been reorganized into two options: GapCover Supreme and GapCover Primary.
- Members can choose between the budget-friendly GapCover Primary and the more comprehensive GapCover Supreme.
Momentum HealthSaver:
- The limit of two transactional cards per contract has been removed.
- Individuals without a South African ID can apply for a HealthSaver Card using their passport.
- Upfront credit for new Momentum HealthSavers will be pro-rated based on the remaining months in the calendar year.
Momentum Multiply:
- Momentum Multiply has transitioned to a program that actively encourages and rewards healthy behaviors.
- A digital health and fitness assessment is available to all members.
- Wysa, an AI-powered emotionally intelligent chatbot, provides mental wellness support.
- Wysa offers evidence-based techniques, self-help resources (mood trackers, journaling, guided exercises), and 24/7 access via the Momentum App.
- Momentum Multiply will use data and personalized insights to provide tailored recommendations and rewards.
- Members can use earned rewards to help cover their monthly medical scheme contributions.
- New partnerships with Ultrahuman, Puma, Multiply Padel, and Travelstart have been established.
General Information:
- Momentum Group Limited and its subsidiaries, as well as Momentum Multiply, are separate from Momentum Medical Scheme.
- Products offered by Momentum are not considered medical scheme benefits.
- Membership in Momentum Medical Scheme can be maintained independently of Momentum's complementary products.

Momentum GapCover:
- The restructuring of Momentum GapCover into GapCover Supreme and GapCover Primary applies to all members. This allows Summit option members to choose between the two based on their needs.
Momentum HealthSaver:
- The removal of the transactional card limit, the acceptance of passports for applications, and the pro-rated credit calculation are changes that affect all HealthSaver users, including those on the Summit option.
Momentum Multiply:
- The enhancements to Momentum Multiply, including the digital health assessment, Wysa chatbot, personalized rewards, and new brand partnerships, are available to all Momentum members, including those on the Summit option.
General Statements:
- The clarification that Momentum's supplementary products are separate from the Momentum Medical Scheme and not medical scheme benefits applies to all members.
- The ability to use multiply rewards to pay for medical aid contributions is available to all members.

In summary, all the listed changes are global changes to the momentum supplementary products, and not changes that are specific to any one medical aid option.

The document outlines general rules regarding waiting periods and late-joiner penalties for Momentum Medical Scheme. It doesn't specify any differences in these rules based on the chosen medical aid option, including the Summit option. Therefore, the information provided applies uniformly to all members, regardless of their selected plan.

Here's a breakdown of the relevant information:

Membership Types and Their Implications:
- Type 1:
  - Applies to individuals with no prior medical coverage or a coverage gap exceeding three months.
  - Subject to a 12-month condition-specific waiting period and a 3-month general waiting period.
  - Not eligible for Prescribed Minimum Benefits (PMBs).
- Type 2:
  - Applies to individuals with less than two years of continuous coverage and a coverage gap of less than three months.
  - Subject to a 12-month waiting period for newly diagnosed conditions and any remaining waiting periods from their previous scheme.
  - Eligible for PMBs.
- Type 3:
  - Applies to individuals with more than two years of continuous coverage and a coverage gap of less than three months.
  - Subject to a 3-month general waiting period.
  - Eligible for PMBs.
Late-Joiner Penalties:
- Applies to applicants or dependents who:
  - Are 35 years or older.
  - Were not members of a registered medical scheme before April 1, 2001.
  - Have had a coverage gap exceeding three months since April 1, 2001.
- Calculation:
  - Formula: A = B - (35 + C)
    - A = Years subject to penalty
    - B = Applicant's age
    - C = Creditable coverage (years on a South African registered medical scheme)
- Penalty Scale:
  - 1-4 years: 5%
  - 5-14 years: 25%
  - 15-24 years: 50%
  - 25+ years: 75%
Application to Summit Option:
- The waiting periods and late-joiner penalties described apply equally to members of the Summit option. There are no specific deviations or exceptions mentioned for this particular plan.

The following is excluded under the Summit 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.

Related to

Overall day-to-day Benefits:

Key Benefits

Major Medical Benefits

Coverage Details:

Chronic and Day-to-Day Benefits

Day-to-Day Benefits

Health Platform Benefit

Coverage for Specialized Procedures and Treatments

Key Procedures and Treatments:

Specific In-Hospital Benefits:

Mental Health

Medical Rehabilitation and Nursing

Emergency Medical Transport

Chronic Benefit

Key Features:

Registration Requirement:

Day-to-Day Benefit

Key Features:

General Healthcare Services

Acupuncture, Homeopathy, Naturopathy, and Related Therapies

Mental Health (Psychiatry and Psychology)

Dentistry

External Medical and Surgical Appliances

General Practitioners and Specialists

Optical and Optometry (Including Contact Lenses and Refractive Eye Surgery)

Pathology and Radiology

Advanced Scans

Prescribed Medication

Preventative Care

Immunizations and Vaccines

Early Detection Tests

Maternity Care Benefits

Pathology Tests for Maternity

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