Focus on the oncology management programme

Below is information about focus on the oncology management programme

We understand that receiving a cancer diagnosis can be an overwhelmingly frightening experience for individuals and their families. To ease this burden, we have taken significant steps to simplify the enrollment process for our oncology program, making it as user-friendly as possible for our members. Our goal is to provide support and assistance during this challenging time, ensuring that our members can access the care they need without unnecessary complications.

How to access the oncology/cancer benefits

Step 1: If you have been diagnosed with cancer, it is essential to consult with a qualified specialist, such as an oncologist or a haematologist. In cases where your diagnosis was not provided by one of these specialists, it is advisable to seek their expertise to ensure you receive appropriate care. The selection of your healthcare provider should be based on the specific type of cancer you are facing. Additionally, it is crucial to choose a network provider that corresponds with your specific benefit option to ensure that you maximize your coverage and minimize out-of-pocket expenses.

Step 2: After you have established a consultation with your doctor, they will create a personalized treatment plan that addresses your unique condition. This proposed treatment strategy will then be submitted to us for pre-authorization. This step is vital as it ensures that your treatment will be covered under your oncology benefits, allowing you to focus on your health rather than financial concerns.

Step 3: To validate your diagnosis, your physician will be required to provide essential medical documentation, which may include histology, pathology, and/or radiology reports. This information should be forwarded to our Oncology Team via email at [e-mail]. Furthermore, your doctor must complete and submit a treatment plan using the designated SAOC/ICON form, ensuring that it includes the necessary ICD-10 codes along with any other relevant details concerning the required treatment.

Step 4: Upon receiving your doctor's submission, our oncology management team will thoroughly review the request. If additional information is needed, we may reach out to either you or your doctor to facilitate the review process and ensure that all aspects of your treatment are considered.

Step 5: Once we have collected all required information, your doctor will receive a response regarding the pre-authorization request within 2 to 3 working days. This timely response is designed to allow for the swift initiation of your treatment, minimizing any delays in your care.

What are the benefit limits?

Benefit option

Ingwe: This option is characterized by an overall annual limit that is restricted to the Prescribed Minimum Benefits available at State facilities. This means that while you will receive essential care, the options may be limited compared to other plans.

Evolve: Beneficiaries enrolled in this option have an overall annual limit of R200,000 per individual per year. Once this limit is reached, a 20% co-payment will apply. The pricing for chemotherapy and adjuvant medications will be based on the Momentum Medical Scheme Reference Pricing. Additionally, benefits under SAOC Tier 1 will be applicable, pending approval, providing further support for your treatment.

Custom: For members in the Custom option, the overall annual limit is R300,000 per beneficiary per year, with a 20% co-payment applicable once this limit is reached. Similar to the Evolve option, the Momentum Medical Scheme Reference Pricing will apply to chemotherapy and adjuvant medications. Furthermore, SAOC Tier 1 benefits are available for both Associated and Any Options, contingent upon approval. In cases that meet specific clinical criteria for exception management, certain specialized oncology medicines and treatments may be accessed on Tier 2 and Tier 3, up to a sub-limit of R200,000 within the overall oncology limit.

Incentive: This benefit option offers an overall annual limit of R400,000 per beneficiary per year. After reaching this limit, a 20% co-payment will be required. The same pricing and benefit structures as outlined for the Custom option apply here, including the same sub-limits for specialized treatments.

Extender: Beneficiaries under this option enjoy a higher overall annual limit of R500,000 per beneficiary per year, with a 20% co-payment applicable thereafter. The pricing and benefit structures remain consistent with those of the Incentive option, ensuring comprehensive coverage.

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

Benefit option and chronic provider

Ingwe: For this option, all oncologists, haematologists, and pharmacies must be sourced from State facilities. This requirement ensures that members receive care that aligns with the available benefits.

Evolve: Members of this option can access oncologists, haematologists, and pharmacies within the Evolve Network of oncology providers. For more details, you can view the list of providers here. It is essential to note that if you choose to utilize a non-network provider for your oncology benefits, you will be responsible for a 20% co-payment on all related expenses, including pathology, radiology, and medications.

Custom, Incentive, and Extender – State chronic provider: For these options, oncologists, haematologists, and pharmacies must be sourced from the ICON Network of oncology providers. Treatment is subject to the ICON Essential Treatment Protocols. As with the Evolve option, using a non-network provider will result in a 20% co-payment for all oncology-related expenses, highlighting the importance of staying within the network.

Custom, Incentive, and Extender – Associated chronic provider: Members have the flexibility to select any SAOC registered oncology provider and utilize Medipost pharmacy for their medications, allowing for a more personalized approach to care.

Custom, Incentive, and Extender – Any chronic provider: Members enjoy the freedom to choose any SAOC registered oncology provider and any pharmacy for their medications, providing maximum flexibility in their treatment options.

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: [e-mail]

Web: momentummedicalscheme.co.za

Support centres for oncology patients

Cancer Association of South Africa (CANSA) - Toll-free: 0800 22 66 22 - Email: [e-mail]

People Living With Cancer (PLWC) - Toll-free: 0800 03 33 37 / 021 565 0039 - Email: [e-mail]

Reach for a Dream - Tel: [phone] - Email: [e-mail] - 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.

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