Focus on the medical rehabilitation benefit

Below is information about Focus on the medical rehabilitation benefit

Physical rehabilitation

Experiencing an illness, injury, accident, or undergoing surgical procedures can often lead to various physical challenges or disabilities that can significantly impact one’s quality of life. Physical rehabilitation is a specialized therapeutic program aimed at helping individuals regain their strength, mobility, and overall independence following such life-altering events. This rehabilitation process can be conducted in different settings; it may take place in the comfort of your own home with assistance from a family member or caregiver, or in a step-down facility designed specifically for recovery. The specific needs of the individual will dictate the most appropriate location for rehabilitation.

In addition to helping you recover physically, physical rehabilitation also prepares you for easier daily living in the future, especially in cases where disabilities may be permanent. The treatments and services that can potentially be covered under the medical rehabilitation benefit include a range of options designed to cater to various needs:

• Step-down facilities: These facilities provide transitional care for patients who have been discharged from acute care hospitals but still require additional support and rehabilitation.
• Occupational therapy: This therapy focuses on helping individuals develop, recover, or maintain daily living and work skills, enabling them to perform essential tasks more independently.
• Speech therapy: Speech therapists assist individuals with communication disorders or swallowing difficulties, helping them regain their ability to speak clearly and effectively.
• Physiotherapy: Physiotherapists work with patients to improve movement and manage pain through physical techniques, exercises, and modalities.
• Wound care: This service involves the management and treatment of wounds to promote healing and prevent infection.
• Stoma care: Stoma care professionals provide specialized support and education to individuals who have undergone surgery resulting in a stoma, helping them adjust to their new circumstances.
• Home nursing: Skilled nursing services can be provided at home for individuals who need medical care but prefer the comfort of their own environment.
• Social workers: Social workers can assist with emotional support, counseling, and connecting patients with community resources to aid in their recovery.

What are the available benefits?

The medical rehabilitation benefits available vary depending on the chosen plan. Here are the options:

• Ingwe Option: This plan provides R15,900 per beneficiary for medical rehabilitation and step-down facilities, but it is important to note that private nursing and hospice services are not included in this coverage.
• Evolve Option: Under this option, families can receive up to R55,000 for medical rehabilitation, private nursing, hospice, and step-down facilities, all subject to case management.
• Custom Option: This plan offers R61,000 per family for medical rehabilitation, private nursing, hospice, and step-down facilities, also subject to case management.
• Incentive Option: Families can access R64,000 for medical rehabilitation, private nursing, hospice, and step-down facilities, with case management applicable.
• Extender Option: This option provides R68,000 per family for medical rehabilitation, private nursing, hospice, and step-down facilities, again subject to case management.
• Summit Option: Similar to the Extender Option, this plan also offers R68,000 per family for the same range of services, subject to case management.

The specific benefits required for rehabilitation will depend on the nature and severity of the injury, illness, procedure, or disability involved.

What is a disability?

A disability can be defined as any condition that hampers an individual's ability to carry out everyday activities. Disabilities can manifest in various forms, including physical, cognitive, mental, sensory, emotional, and developmental challenges, or a combination thereof. They may be present from birth, develop over the course of a lifetime, or arise as a result of a traumatic event. Disabilities can be visible or hidden, permanent or temporary, and may have a minimal or substantial impact on a person’s capabilities.

For instance, recovery from surgeries such as hip replacements or heart bypasses are examples of physical disabilities. Sensory disabilities can affect one’s sight, hearing, smell, touch, and taste. Cognitive disabilities impact brain function, which may include memory loss following a head injury or stroke. Intellectual disabilities are characterized by below-average intellectual functioning, while mental health issues like severe depression or schizophrenia fall under the category of mental disabilities.

What is physical rehabilitation?

Often, we take for granted the simple ability to move, bend, lift, throw, or push without any limitations. However, an injury or illness can strip away these capabilities, turning everyday tasks into monumental challenges. Physical rehabilitation is the systematic process of restoring and regaining physical strength and functionality, facilitated by a collaborative team of specialists. This team typically includes doctors, nurses, psychologists, physiotherapists, social workers, speech therapists, and occupational therapists, all working together to create a comprehensive recovery plan tailored to the individual’s needs.

Who is eligible?

Eligibility for medical rehabilitation benefits is generally extended to members who have experienced a significant life-altering event or injury that typically requires hospitalization for treatment. A discharge plan created by your treating doctor is essential for this process. This plan will be tailored to your specific condition and usually includes details regarding follow-up visits, necessary investigations, prescribed medications, medical devices or appliances, a rehabilitation plan, and, when suitable, a transfer to a step-down facility or hospice.

The rehabilitation plan may also involve a thorough evaluation of your home environment to ensure it is safe and accommodating for your needs during the rehabilitation process. A case manager from the Momentum Medical Scheme will monitor your recovery progress, collaborating closely with your healthcare team to ensure effective rehabilitation.

It is important to note that medical schemes cannot provide unlimited funding for rehabilitation services. Depending on the severity of your injuries, it is possible that you may not regain 100% of the functionality you previously had. Each case is unique, and while the intention is to support our members in accessing benefits, funding cannot continue indefinitely. Coverage will cease once you reach a point where no further functional benefit is expected, or if progress is evident through the transfer of skills to a caregiver or family member. Additionally, it is crucial to understand that frail care is excluded from this benefit.

How to register for treatment in a step-down facility

To initiate the registration process for treatment in a step-down facility, the following steps must be followed:

1. First, a letter of motivation from your treating doctor is required, which should include a comprehensive clinical report detailing:
   • The diagnosis and corresponding ICD-10 code;
   • The current clinical condition of the patient;
   • The estimated length of stay if transferring from another facility;
   • A completed assessment from a facility that holds a valid practice number; and
   • The treatment plan, including the requested length of stay and tariff codes for all services, such as those provided by physiotherapists and social workers.
2. Your treating doctor or hospital case manager can then send this letter of motivation to us via email at [e-mail]. The discharge plan will be evaluated by one of our case managers based on clinically appropriate protocols and evidence-based medicine.
3. We will respond to your treating doctor or hospital case manager within 48 hours regarding the request.
4. If there is a need to appeal a decision, you can do so by emailing us at [e-mail]. We will review the appeal and provide feedback accordingly.

How to register for home nursing or Hospice

To register for home nursing or hospice services, please follow these steps:

1. A letter of motivation from your treating doctor is required, which must include a detailed clinical report that outlines:
   • The diagnosis and ICD-10 code;
   • The current clinical condition of the patient;
   • The estimated duration for which the service will be required;
   • A completed assessment from a facility with a valid practice number; and
   • The treatment plan or services that will be provided, including the relevant tariff codes for billing.
2. We will provide a response to your treating doctor or nursing agency within 48 hours.
3. If an appeal of a decision is necessary, you can email us at [e-mail]. We will review the appeal and offer feedback.

How to register for wound care

To register for wound care services, please follow these steps:

1. A letter of motivation from your treating doctor is required, which should include a detailed clinical report from the nursing sister who will be administering the wound care. This report must outline:
   • The diagnosis and ICD-10 code;
   • Current dated, color photographs of the wound;
   • The estimated dates for the necessary wound care;
   • The valid practice number of the nursing sister;
   • The tariff codes associated with the wound care; and
   • A list of all items and dressings required for the treatment.
2. We will respond to your treating doctor or nursing sister within 48 hours regarding the request.
3. If an appeal is necessary, you can email us at [e-mail]. We will review the appeal and provide feedback.

It is important to note that updated progress reports from the treating providers must be submitted weekly to the Scheme. This requirement ensures that we can effectively monitor the rehabilitation progress and align it with the benefits provided.