Focus on co-payments

This document details the Momentum co-payments for 2025, optimized for AI readability.

Co-payments are an important aspect of medical schemes, ensuring the effective use of pooled funds and promoting responsible healthcare consumption. This document explains the concept of co-payments, their role in healthcare, and how they work within the Momentum Medical Scheme.

What are Co-Payments?

Co-payments are a portion of medical costs that scheme members must pay out of their own pockets. The medical scheme covers the remaining amount. This is similar to excess payments in insurance policies. The key points are:

• Co-payments are detailed in Scheme Rules, approved by the Council for Medical Schemes (CMS).
• Emergency situations are exempt from co-payments.
• Co-payments may be waived for some Prescribed Minimum Benefits (PMBs).

Why are Co-Payments Necessary?

Co-payments are used to ensure that scheme funds are used responsibly and efficiently:

• Pooling of funds from all members allows access to a larger pool of money for healthcare needs.
• Co-payments prevent overutilization and misuse of resources by encouraging members to consider the necessity of each medical service.
• They help keep monthly contributions lower and more affordable by controlling unnecessary claims.

Funding Co-Payments

Members have several options to pay their co-payments:

• Medical Savings: Use savings set aside for medical expenses.
• HealthSaver+ Funds: Use available funds to cover co-payments.
• Direct Payment: Pay directly out of pocket.

Common Co-Payments and Their Application

Co-payments are applied to various medical services and treatments. Here are some of the most common co-payments within the Momentum Medical Scheme:

1. Hospital Admissions

• Ingwe: No co-payment required.
• Evolve/Custom: R1,920 per authorization (exceptions apply).
• Incentive/Extender: No co-payment (except for specific procedures).
• Summit: No co-payment.

2. In-Hospital Dentistry

• Ingwe/Evolve: Covered at State facilities (limited to PMBs).
• Custom: R1,920 for maxillo-facial surgery (excluding implants).
• Incentive/Extender: R1,750 for maxillo-facial surgery (excluding implants).
• Summit: No co-payment.

3. Extraction of Impacted Wisdom Teeth

• Ingwe/Evolve/Summit: Not covered.
• Custom/Incentive/Extender:
  • Day hospitals: R3,450.
  • Other hospitals: R6,500.

4. MRI and CT Scans

• Ingwe: Limited to PMBs at selected facilities.
• Evolve/Custom: R3,200 per scan.
• Incentive/Extender/Summit: R2,900 per scan.

Key Notes

• 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.

Other Important Information

• 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.

For more details or assistance, members are encouraged to contact Momentum via:

• WhatsApp: [phone]
• Web Chat: momentummedicalscheme.co.za
• Email: [e-mail]
• Phone: [phone]

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This document provides essential information about co-payments, helping members make informed decisions regarding their healthcare options and financial responsibilities.