Custom Option Brochure

Member Our 2025 Guide benefits Our 2025 benefits Benefit schedule Obtaining pre-authorisation for Major Medical Benefits Using your Health Platform Benefits Registering for Chronic Benefits Claiming from Momentum Medical Scheme Claiming for third party injuries and motor vehicle accidents Claiming for injuries at work Registering for a health management programme Registering for oncology benefits Membership Complaints procedure Digital access Chronic conditions Specialised procedures/ treatment Exclusions List of Associated hospitals Glossary of terms 2 8 10 11 14 15 16 17 18 20 22 22 23 24 25 26 28 Choose your providers Choose your family composition Hospital Chronic Associated Any R3 393 R6 070 R4 589 R7 266 R8 462 R9 658 Associated R3 033 R5 385 R4 105 R6 457 R7 529 R8 601 State R2 353 R4 133 R3 187 R4 967 R5 801 R6 635 Any Any R4 047 R7 295 R5 491 R8 739 R10 183 R11 627 Associated R3 596 R6 406 R4 903 R7 713 R9 020 R10 327 State R2 997 R5 259 R4 095 R6 357 R7 455 R8 553 All benefits are subject to Prescribed Minimum Benefits. This member brochure summarises the benefits available to you on the Custom Option. Scheme Rules will always take precedence and are available by submitting a request on momentummedicalscheme.co.za, emailing us at [e-mail], sending us a WhatsApp message or calling us on 0860 11 78 59. + Momentum Medical Scheme members may choose to make use of additional products available from Momentum Group Limited and its subsidiaries as well as Momentum Multiply (herein collectively referred to as Momentum). Momentum is not a medical scheme and is a separate entity to Momentum Medical Scheme. Momentum products are not medical scheme benefits. You may be a member of Momentum Medical Scheme without taking any of the products offered by Momentum. The contributions exclude any late joiner penalties payable. Contributions payable for family sizes not mentioned above are available from our member contact centre or from your healthcare adviser. Maximum of 3 children charged for. Major Medical Benefit General rule You need to contact us for pre-authorisation before making use of your Major Medical Benefits, such as when you are admitted to hospital. You must obtain a separate pre-authorisation from Momentum Medical Scheme for any in-hospital physiotherapy. For some conditions, like cancer, you will need to register on a health management programme. Momentum Medical Scheme will pay benefits in line with the Scheme Rules and the clinical protocols that Momentum Medical Scheme has established for the treatment of each condition. We provide authorisation subject to the principles of funding allocation, which are based on proven evidence-based medicine, clinical appropriateness and cost effectiveness. If you do not get pre-authorisation, the Scheme will only cover 70% of the accounts, at the agreed negotiated rates, except in the case of a medical emergency. Hospital accounts are covered in full at the rate agreed upon with the hospital group. Accounts for Associated specialists are covered in full. Accounts for other specialists are covered up to 100% of the Momentum Medical Scheme Rate. You have either chosen to have access to any hospital, or you chose to use Associated hospitals (see pages 26 and 27 for the list of Associated hospitals). The sub-limits specified apply per year. Should you not join in January, your sub-limits will be adjusted pro-rata (which means it will be adjusted in line with the number of months left in the year). Hospital provider Any or Associated hospitals Overall annual limit No overall annual limit applies Co-payments You will have a co-payment of R1 920 per authorisation, except for motor vehicle accidents, maternity confinements and emergency treatment. This co-payment applies even in the case of Prescribed Minimum Benefits, excluding emergencies If you chose Associated hospitals and do not use this provider, you will have a co-payment of 30% on the hospital account An additional co-payment may also apply per authorisation to specialised scans, dental benefits and certain specialised procedures/treatment - see table below Specialised procedures/treatment co-payments The standard Custom Option co-payment of R1 920 per authorisation applies to these procedures and treatments regardless of where they are performed Plus the Specialised Procedures/Treatment co-payment of R1 920 per authorisation applies if performed in a day hospital, or R3 840 per authorisation if performed in an acute hospital (hospital where overnight admissions apply) Arthroscopies, Back and neck surgery, Carpal tunnel release, Functional nasal and sinus procedures, Joint replacements, Laparoscopies Performed in a day hospital or acute hospital, subject to the relevant co-payment listed above Gastroscopies, Colonoscopies, Cystoscopies, Sigmoidoscopies, Nail surgery, Removing of extensive skin lesions Performed out of hospital, in a day hospital or in an acute hospital, subject to the relevant copayment listed above Conservative back and neck treatment Removal of minor skin lesions, Treatment of diseases of the conjunctiva, Treatment of headache, Treatment of adult influenza, Treatment of adult respiratory tract infections Low severity cases are not covered by the Scheme but can be paid from Momentum HealthSaver+, if available High severity cases in an acute hospital are paid by the Scheme, subject to the relevant co-payment listed above View the list of day hospitals on the Momentum App or momentummedicalscheme.co.za + Momentum HealthSaver is a complementary product offered by Momentum * Beneficiaries who have selected State as their chronic provider, need to make use of State facilities for renal dialysis ** Beneficiaries who have selected State as their chronic provider must obtain their oncology treatment from an oncologist authorised by Momentum Medical Scheme Benefit schedule Consultations and visits Associated specialists covered in full Other specialists covered up to 100% of the Momentum Medical Scheme Rate High and intensive care No annual limit applies Casualty or after-hours visits Subject to Momentum HealthSaver+ , if available Renal dialysis* No annual limit applies Oncology** R300 000 per beneficiary per year, thereafter a 20% copayment applies. Momentum Medical Scheme reference pricing may apply to chemotherapy and adjuvant medication Organ transplants (recipient) No annual limit applies Organ transplants (donor). Only covered when recipient is a member of Momentum Medical Scheme R24 900 cadaver costs R50 400 live donor costs (including transportation) In-hospital dental and oral benefits - maxillo-facial surgery (excluding implants) and general anaesthesia for children under 7 The hospital account is paid at the negotiated rate, subject to a R1 920 co-payment per authorisation. The anaesthetist account is covered up to 100% of the Momentum Medical Scheme Rate. The dental, dental specialist and maxillo-facial surgeon accounts are paid from HealthSaver+ , if available - dentistry related to trauma The hospital account is paid at the negotiated rate. The anaesthetist, dentist, dental specialist and maxillo-facial surgeon accounts are covered up to 100% of the Momentum Medical Scheme Rate - extraction of impacted wisdom teeth The hospital account is paid at the negotiated rate, subject to a R3 450 co-payment for day hospitals and a R6 500 co-payment for other hospitals per authorisation. The anaesthetist, dentist, dental specialist and maxillo-facial surgeon accounts are paid up to 100% of the Momentum Medical Scheme Rate - implants and all other in-hospital dental treatment The cost of implants, as well as the hospital, anaesthetist, dentist, dental specialist and maxillo facial surgeon accounts are subject to HealthSaver+, if available Maternity confinements No annual limit applies Neonatal intensive care No annual limit applies MRI and CT scans, magnetic resonance cholangiopancreatography (MRCP), whole body radioisotope and PET scans (in- and out-of-hospital) No annual limit applies, subject to R3 200 co-payment per scan Medical and surgical appliances in-hospital (such as support stockings, knee and back braces, etc) R8 030 per family Prosthesis – internal (including knee and hip replacements, permanent pacemakers, cochlear implants, etc.) Intraocular lenses: R6 900 per beneficiary per event, maximum 2 events per year Other internal prostheses: R59 000 per beneficiary per event, maximum 2 events per year Prosthesis - external (such as artificial arms or legs) R28 000 per family Mental health - including psychiatry and psychology - drug and alcohol rehabilitation R45 300 per beneficiary Take-home medicine 7 days’ supply Medical rehabilitation, private nursing, Hospice and step-down facilities R64 000 per family (combined limit), subject to case management Health management programmes for conditions such as chronic renal disease, organ transplants, mental health, HIV/Aids and oncology Your doctor needs to register you on the appropriate health management programme 2 3 Benefit schedule Chronic Benefit Benefits are subject to registration on the Chronic Management Programme and approval by the Scheme. Provider Any, Associated or State Cover 26 conditions, according to the Chronic Disease List in the Prescribed Minimum Benefits (see page 23 for a list of conditions covered) The chronic provider you have chosen determines how and from where you get your chronic treatment, prescription and medication. Any: You can get your chronic prescription and medication from any provider, subject to a Basic formulary. Associated: You must get your chronic prescription from an Associated GP and your chronic medication from Medipost, subject to a Core formulary. State: You must choose one of the designated State facilities to obtain your chronic treatment, prescription and medication, subject to a State formulary. Chronic provider Chronic prescription Chronic medication provider Chronic formulary Any Any GP or specialist Any specialist, dispensing GP or pharmacy Basic formulary Associated Associated GP or Associated specialist Medipost Courier Pharmacy Core formulary State State facility State facility State formulary Day-to-day Benefit General rule If you would like cover for day-to-day expenses, you can make use of the Momentum HealthSaver+ (see separate Momentum Complementary Product brochure for more information). Provider Any Acupuncture, Homeopathy, Naturopathy, Herbology, Audiology, Occupational and Speech therapy, Chiropractors, Dieticians, Biokinetics, Orthoptists, Osteopathy, Audiometry, Chiropody, Physiotherapy and Podiatry Subject to Momentum HealthSaver+, if available Mental health (including psychiatry and psychology) Subject to Momentum HealthSaver+, if available Dentistry – basic (such as extractions or fillings) Subject to Momentum HealthSaver+, if available Dentistry – specialised (such as bridges or crowns) Anaesthetist and dental specialist accounts for extraction of impacted wisdom teeth in doctors’ rooms: Covered from Major Medical Benefit at 100% of the Momentum Medical Scheme Rate, subject to R1 920 co-payment and preauthorisation Other specialised dentistry: Subject to HealthSaver+ if available External medical and surgical appliances (including hearing aids, glucometers, blood pressure monitors, wheelchairs, etc) Subject to Momentum HealthSaver+, if available General practitioners Subject to Momentum HealthSaver+, if available Specialists Subject to Momentum HealthSaver+, if available Optical and optometry (including contact lenses and refractive eye surgery) Subject to Momentum HealthSaver+, if available Pathology (such as blood sugar or cholesterol tests) Subject to Momentum HealthSaver+, if available Radiology (such as x-rays) Subject to Momentum HealthSaver+, if available MRI and CT scans, magnetic resonance cholangiopancreatography (MRCP), whole body radioisotope and PET scans Covered from Major Medical Benefit, subject to pre-authorisation and a co-payment of R3 200 per scan Prescribed medication Subject to Momentum HealthSaver+, if available Over-the-counter medication Subject to Momentum HealthSaver+, if available + Momentum HealthSaver is a complementary product available from Momentum Benefit schedule Immune deficiency related to HIV Anti-retroviral treatment HIV related admissions No annual limit applies at preferred provider R85 600 per family at your chosen hospital provider Emergency medical transport in South Africa by Netcare 911 No annual limit applies International emergency medical transport by preferred provider R7 660 000 per beneficiary per 90-day journey. This benefit includes R15 500 for emergency optometry, R15 500 for emergency dentistry and R765 000 terrorism cover A R2 180 co-payment applies per emergency out-patient claim Specialised procedures/treatment (refer to page 24 for a list of procedures covered) Certain specialised procedures/treatment covered, when clinically appropriate, in- or out-of-hospital Major Medical Benefit (continued) 4 5 Benefit schedule Health Platform Benefit General rule Health Platform Benefits are paid by the Scheme up to a maximum rand amount per benefit. The maximum rand amount is determined according to specific tariff codes. You do not need to pre-notify before using Health Platform Benefits, except for preventative dental care, pap smears, HPV screening tests, general physical examinations and HIV tests. Where pre-notification is required, you can pre-notify quickly and easily on the Momentum App, via the web chat facility or by logging on to momentummedicalscheme.co.za. You may also send us a WhatsApp or call us on 0860 11 78 59. Please note * If you chose Associated as your chronic provider, a 30% co-payment will apply if you do not use an Associated GP for GP consultations covered under the Health Platform Benefit ** Only covered if in-person health assessment results indicate a total cholesterol of 6 mmol/l and above *** Only covered if in-person health assessment results indicate blood sugar levels are 11 mmol/l and aboveare 11 mmol/l and above Benefit Who? How often? Preventative care Baby immunisations Children up to age 6 As required by the Department of Health Flu vaccines Children between 6 months and 5 years Beneficiaries 60 and older High-risk beneficiaries Once a year Tetanus diphtheria injection All beneficiaries As needed Pneumococcal vaccine Beneficiaries 60 and older High-risk beneficiaries Once a year Early detection tests Preventative dental care covered up to R380 per beneficiary at dentists, dental therapists and oral hygienists All beneficiaries Once a year Pap smear consultation (nurse, GP or gynaecologist) Women 15 and older Based on type of pap smear (see below) Pap smear (pathologist) - Standard or LBC (Liquid based cytology) or Women 15 and older Once a year - HPV PCR screening test (If result indicates high risk, then a follow-up LBC is also covered) Women 21 to 65 Once every 3 years Mammogram Women 38 and older Once every 2 years DEXA bone density scan (radiologist, GP* or specialist) Beneficiaries 50 and older Once every 3 years General physical examination (GP* consultation) Beneficiaries 21 to 29 Beneficiaries 30 to 59 Beneficiaries 60 to 69 Beneficiaries 70 and older Once every 5 years Once every 3 years Once every 2 years Once a year Prostate specific antigen (pathologist) Men 40 to 49 Men 50 to 59 Men 60 to 69 Men 70 and older Once every 5 years Once every 3 years Once every 2 years Once a year Health assessment available digitally on the Momentum App or in person at Dis-Chem, Clicks, MediRite or Pick n Pay pharmacy clinics All principal members and adult beneficiaries Once a year Cholesterol test (pathologist)** Principal members and adult beneficiaries Once a year Blood sugar test (pathologist)*** Principal members and adult beneficiaries Once a year Glaucoma test Beneficiaries 40 to 49 Beneficiaries 50 and older Once every 2 years Once a year HIV test (pathologist) Beneficiaries 15 and older Once every 5 years Maternity programme (subject to registration on the Maternity management programme between 8 and 20 weeks of pregnancy) Doula benefit (your gynaecologist must be an Associated Specialist) Women registered on the programme 2 visits, covered up to R2 300 per confinement Antenatal visits (Midwives, GP* or gynaecologist) 12 visits Nurse home visits 2 visits, 1 on the day after returning from hospital, and a follow-up visit 2 weeks later Pathology tests Blood group, full blood count, Rhesus factor, creatinine, glucose strip, haemoglobin estimation Women registered on the programme 1 test Urinalysis 12 tests Urine tests (microscopic exams, antibiotic susceptibility and culture) As indicated Urine tests (dipstick) Women registered on the programme Included in antenatal visits Scans 2 pregnancy scans 3D and 4D scans covered up to the rate we pay for 2D scans Paediatrician visits Babies up to 12 months registered on the programme 2 visits in baby’s first year Health line 24-hour emergency health line All beneficiaries As needed 6 7 You must obtain pre-authorisation from Momentum Medical Scheme for: — hospitalisation — day hospital admissions — specialised procedures/treatments — MRI and CT scans, magnetic resonance cholangiopancreatography (MRCP), whole body radioisotope and PET scans (you have to be referred by a specialist) — all other Major Medical Benefits. You must obtain a separate pre-authorisation from Momentum Medical Scheme for any in-hospital physiotherapy. We provide pre-authorisation once benefits have been verified and Scheme Rules have been applied. If the hospital, doctor or any other third party obtains the authorisation on your behalf, it is important for you to check if you will need to pay any co-payments as a result of not using a Designated Service Provider, Preferred Provider or Network Provider, or as a result of any benefit limits. While pre-authorisation is not a guarantee that your treatment will be covered, it gives you the peace of mind that benefits will be paid in line with Scheme Rules, your option and membership status. How to obtain authorisation: 1. You can easily obtain authorisation via the Momentum App. 2. Alternatively, contact us via the web chat facility on momentummedicalscheme.co.za, email us at [e-mail], send us a WhatsApp message or call us on 0860 11 78 59. 3. Make a note of the authorisation number. 4. Give the authorisation number to your service provider. Information needed when obtaining an authorisation: — membership number — the name and details of the patient — the reason for hospital admission, procedure or specialised scan — the procedure code (CPT), diagnosis code (ICD-10) and tariff code (these details are available from your treating doctor) — the date of admission — the contact details and practice number of the referring GP — the contact details and practice number of the specialist — the name and practice number of the hospital, day hospital or radiologist. Frequently asked questions Q If I have chosen Associated hospitals as my in-hospital provider, how do I confirm which hospitals are on the Associated hospitals list? A See the list of Associated hospitals on page 26 and 27. You can also obtain the list on the Momentum App or by logging on to momentummedicalscheme.co.za. Alternatively, you can contact us via the web chat facility on momentummedicalscheme.co.za, email us at [e-mail], send us a WhatsApp message or call us on 0860 11 78 59. Q Can an authorisation number be issued on the day of admission? A You need to get authorisation at least 48 hours before admission, unless it is an emergency admission. Q What happens if it is an emergency admission? A You, a family member or a friend, must contact us within 72 hours of admission. Q What if I do not get authorisation in time? A A co-payment of 30% will apply to all claims relating to the treatment and hospital account. Momentum Medical Scheme will be responsible for 70% of the negotiated tariffs, provided authorisation would have been granted according to the Rules of the Scheme. Q What if I need to stay in hospital longer than the period that was originally authorised? A The hospital needs to contact us to update the length of stay. Q How does authorisation work for childbirth? A Contact us within 30 days of your due date to ask for authorisation for your confinement. If your admission date changes, you have 48 hours from the date of admission to notify us. Q Do I need pre-authorisation to use my prosthesis benefit? A Yes, you need to obtain pre-authorisation before using your prosthesis benefit. When you contact us for preauthorisation you should tell our contact centre consultant that a prosthetic device will be used, and he/she will confirm the benefit you have available for prostheses. Q What if my prosthesis limit is insufficient based on what the doctor has told me the cost will be? A Although the shortfall between the prosthesis limit and the cost indicated by your doctor will be for your pocket, Momentum Medical Scheme will assist you in getting competitive quotes to try and minimise shortfalls, where possible. Q What if the State cannot provide me with treatment for renal dialysis? A If the State cannot provide you with the treatment you need for renal dialysis, the treating doctor or administration staff at the hospital needs to confirm this in writing. Once this is received, you need to contact us to obtain a list of alternative renal providers authorised by Momentum Medical Scheme. Important notes If you have selected Associated hospitals for your hospital benefits, but obtain services from a hospital which is not on the Associated list, you will have a 30% co-payment on the hospital account, except in the case of emergency medical conditions*. Refer to page 26 and 27 for a list of the Associated hospitals. *Emergency medical condition means the sudden and, at the time, unexpected onset of a health condition that requires immediate medical or surgical treatment, where failure to provide medical or surgical treatment would result in serious impairment to bodily functions or serious dysfunction of a bodily organ or part, or would place the person’s life in serious jeopardy. Momentum Medical Scheme is allowed to stipulate Designated Service Providers from which all members should obtain Prescribed Minimum Benefits, in order to enjoy full cover for these benefits. Momentum Medical Scheme’s Designated Service Providers for Prescribed Minimum Benefits are Associated GPs, Specialists and Pharmacies, as well as State facilities, depending on the circumstances. Log on to momentummedicalscheme.co.za to view the providers in your area, or contact us via the web chat facility on momentummedicalscheme.co.za, email us at [e-mail], send us a WhatsApp message or call us on 0860 11 78 59. Treatment for Prescribed Minimum Benefits is subject to Momentum Medical Scheme’s clinical protocols (see Glossary of Terms on page 28). Obtaining pre-authorisation for Major Medical Benefits 8 9 Chronic benefits are subject to registration and approval. Your choice of chronic provider determines how and from where you get your chronic treatment, prescription and medication. Any provider The Any chronic provider choice allows you to get your chronic prescription and medication from any provider, subject to a Basic formulary. If you choose to get your medication from the preferred list of medicines, and within the Momentum Medical Scheme Reference Price if applicable, you will not have a co-payment. However, if your preferred medication costs more than the Momentum Medical Scheme Reference Price, you will have a co-payment for the difference in cost. If you choose to get non-preferred medication, a 15% co-payment will apply. However, if your non-preferred medication costs more than the Momentum Medical Scheme Reference Price, a co-payment for the difference in cost will be added to the 15% co-payment. To check whether any of the above co-payments would apply to your chronic medication, visit momentummedicalscheme.co.za and make use of the formulary search function, contact us via the web chat facility on momentummedicalscheme.co.za, email us at [e-mail], send us a WhatsApp message or call us on 0860 11 78 59. A dispensing fee co-payment may also be payable when using pharmacies not contracted to Momentum Medical Scheme. Contracted pharmacies include Clicks, Dis-Chem, MediRite and Medipost (for the full list, log on to momentummedicalscheme.co.za or contact us via the web chat facility on momentummedicalscheme.co.za, email us at [e-mail], send us a WhatsApp message or call us on 0860 11 78 59). How to register for chronic medication 1. Your treating doctor or pharmacist needs to call us on 0860 11 78 59 and select option 2. 2. The chronic benefit consultant will approve or decline the benefit telephonically, as per clinical protocols. 3. We may need additional information, such as test results, from your provider in order to complete the chronic registration process. 4. You may obtain medication from any pharmacy. 5. Your prescription must be renewed every 6 months with your pharmacy. Information needed when the provider calls: — your membership number, and the name and details of the patient — the diagnosis code (ICD–10 code) — the name and practice number of your treating GP/specialist where relevant. Frequently asked questions Q What if the prescribed chronic medication needs to change or additional medication is required? A Your treating doctor or pharmacist needs to call us on 0860 11 78 59. The change will be done telephonically and approval is given immediately, subject to criteria being met. You must also provide the updated script to your pharmacy. Q What if a new chronic condition is diagnosed? A You can check if the new chronic condition is covered (see page 23 for the list of chronic conditions that are covered). Your treating doctor or pharmacist needs to call our contact centre. The additional authorisation will be done telephonically and approval is given immediately, subject to criteria being met. Important notes If you do not obtain approval from us for your chronic benefits, your chronic treatment will be paid from Momentum HealthSaver+, if available. If you do not have available Momentum HealthSaver+ funds, you will need to pay for your chronic treatment from your own pocket. You will need to pay for all medication and/or services that are not approved by Momentum Medical Scheme. Pharmacy dispensing fees will be paid at the Momentum Medical Scheme Rate for medicine. Using your Health Platform Benefits You do not need to pre-notify before using Health Platform Benefits, except for preventative dental care, pap smears, HPV screening tests, general physical examinations and HIV tests. 1. Where pre-notification is required, you can pre-notify quickly and easily on the Momentum App, via the web chat facility or by logging on to momentummedicalscheme.co.za. You may also send us a WhatsApp or call us on 0860 11 78 59. 2. Take note of the authorisation number and tariff code. 3. Give the authorisation number and the tariff code to your service provider. Information needed when notifying us: — your membership number — the name and details of the patient — the details of the benefit you will be using. Frequently asked questions Q What is a tariff code? A This is a standard healthcare industry code that identifies the type of procedure done or service provided by the healthcare provider. Q Why is it important to notify our member contact centre before certain Health Platform Benefits are used? A When you pre-notify, an authorisation number is created, which makes it possible for your claim to be paid from the Health Platform Benefit. If you do not pre-notify for preventative dental care, pap smears, HPV screening tests, general physical examinations and HIV tests, your claim will not be paid from the Health Platform Benefit, but from Momentum HealthSaver+ , if available. Important notes If you chose Associated as your chronic provider, a 30% co-payment will apply if you do not use an Associated GP for GP consultations covered under the Health Platform Benefit. + Momentum HealthSaver is a complementary product available from Momentum Registering for Chronic Benefits 10 11 Associated provider If you have chosen the Associated chronic provider, you need to get your chronic prescription from an Associated GP or an Associated Specialist and your chronic medication from Medipost, subject to a Core formulary. If you choose to get your chronic prescription from a non-Associated GP or specialist, we will pay 50% of the Momentum Medical Scheme Rate for the consultation and you will need to pay the difference. If you choose to get your chronic medication from a pharmacy other than Medipost, we will pay 50% of the formulary price for the medicine and you will need to pay the difference. If you choose to get either preferred or non-preferred medication in the formulary, which costs more than the Momentum Medical Scheme Reference Price, there will be a co-payment for the difference in cost. How to register for chronic medication 1. Your treating doctor or pharmacist needs to call our contact centre on 0860 11 78 59 and select option 2. 2. The chronic benefit consultant will approve or decline the benefit telephonically, as per clinical protocols. 3. Additional information, such as test results, may be required from your provider in order to complete the chronic registration process. 4. You must submit your prescription to Medipost. 5. Your medication will be sent to you. 6. Your prescription must be renewed every 6 months with Medipost. Medipost Tel: [phone] Email: [e-mail] Information needed when the provider calls: — your membership number — the name and details of the patient — the diagnosis code (ICD–10 code) — the name and practice number of your treating GP/specialist where relevant. Frequently asked questions Q What if there is a change in the prescribed medication or additional medication is required? A Your treating doctor needs to call our contact centre on 0860 11 78 59. The change will be done telephonically and approval is given immediately, subject to criteria being met. You must also provide the updated script to Medipost. Q What if a new condition is diagnosed? A You can check if the new chronic condition is covered (see page 23 for the list of chronic conditions that are covered). Your treating doctor or pharmacist needs to call our contact centre. The additional authorisation will be done telephonically and approval is given immediately, subject to criteria being met. Q What if I do not use Medipost to get my chronic medicine? A Medipost pharmacy is Momentum Medical Scheme’s designated Courier pharmacy. If you choose to get your chronic medication from a pharmacy other than Medipost, we will pay 50% of the formulary price for the medicine. Important notes If you do not obtain approval from Momentum Medical Scheme for your chronic benefits, your chronic treatment will be paid from Momentum HealthSaver+, if available. If you do not have available Momentum HealthSaver+ funds, you will need to pay for your chronic treatment from your own pocket. You will need to pay for all medication and/or services that are not approved by Momentum Medical Scheme. Pharmacy dispensing fees will be paid at the Momentum Medical Scheme Rate for medicine. State provider If you have chosen State as your chronic provider, you need to use State facilities to obtain your chronic treatment, prescription and medication, subject to the State formulary. How to register for chronic medication 1. Contact us via the web chat facility on momentummedicalscheme.co.za, email us at [e-mail], send us a WhatsApp message or call us on 0860 11 78 59 and ask for for a State chronic application form. 2. Ask the State doctor to complete the form. The doctor may also contact us telephonically. 3. The State doctor will assess the patient and prescribe medication as per the State formulary. Please discuss this with the treating State doctor at the State facility. 4. Medication will need to be collected from the State hospital pharmacy once the treating doctor provides the patient with a script or relevant document with the medication details. 5. Email the completed form to us, together with any relevant information/supporting documents to help in processing the application. Frequently asked questions Q What if there is a change in the prescribed chronic medication or additional medication is required? A Email a new State chronic application form, completed and signed by you and the State doctor, to us. Q What if a new condition is diagnosed? A Email a new State chronic application form, completed and signed by you and the State doctor, to us. Q What if the State facility cannot provide me with the chronic medicine that I need for a chronic condition contained in the Prescribed Minimum Benefits Chronic Disease List? A If the State cannot provide you with the chronic medicine you need for a chronic condition contained in the Prescribed Minimum Benefits Chronic Disease List, the treating doctor or administration staff at the hospital needs to confirm this in writing on the State chronic application form. Once this is received, you may obtain your medicine from an Ingwe Primary Care Network doctor, subject to a Fixed formulary and Scheme approval. A list of the Ingwe Primary Care Network doctors is available on momentummedicalscheme.co.za. If you choose not to use these Designated Service Providers, you will be liable for a co-payment. Important notes If you do not obtain approval from us for your chronic benefits, your chronic treatment will be paid from Momentum HealthSaver+, if available. If you do not have available Momentum HealthSaver+ funds, you will need to pay for your chronic treatment from your own pocket. You will need to pay for all medication and/or services that are not approved by Momentum Medical Scheme. If you have selected State as your chronic provider, you must obtain your chronic medication and treatment from a State facility. + Momentum HealthSaver is a complementary product available from Momentum Registering for Chronic Benefits (continued) 12 13 1. Upload a photo of your claim on the Momentum App or email it to us. 2. Information that must be on the claim: – your membership number – the principal member’s surname, initials and first name – the patient’s surname, initials and first name – the treatment date – the amount charged – the ICD–10 code, tariff code and/or nappi code – the service provider’s name and practice number – proof of payment if you have paid the claim. Important notes Ensure your correct membership number is included on the claim. Email: [e-mail] Frequently asked questions Q How long are claims valid for? A If Momentum Medical Scheme does not receive a claim by the last day of the 4th month following the month in which the service was rendered, the claim will be stale and you will need to pay any outstanding amounts to the provider. Q Can I submit only the receipt for reimbursement? A No, a detailed claim must be submitted, as it contains important information needed to process the claim (see details of the information needed under the Claiming from Momentum Medical Scheme section above). Q If I have already paid the claim, how will Momentum Medical Scheme know to refund me instead of paying the provider? A Include the proof of payment with your claim, or you can ask the provider to stamp the claim as paid. Important notes The majority of claims from providers, such as doctors, dentists and hospitals, are submitted directly by the provider to us for payment. However, it still remains your responsibility to ensure that your claims are submitted timeously. If you have paid the provider directly, please submit your receipt with a detailed copy of the claim for reimbursement. Third party injuries are where another party was responsible for the injury and therefore may be liable for medical expenses. Any amount recovered, such as from the Road Accident Fund (in the case of motor vehicle accidents), for hospital and medical expenses must be refunded to Momentum Medical Scheme, if these expenses were paid on your behalf by us. Please remember to: 1. Report the accident or incident to the police and obtain a case number. 2. Contact us via the web chat facility on momentummedicalscheme.co.za, email us at [e-mail], send us a WhatsApp message or call us on 0860 11 78 59 for authorisation. Information needed when contacting us: – your membership number – the principal member’s surname, initials and first name – the full name(s) of the person(s) involved in the accident – the date of the accident or incident. 3. In the case of a motor vehicle accident, you will be asked to sign an undertaking whether or not you will be claiming from the Road Accident Fund. The signed undertaking is required to finalise the processing of your claim. 4. If you acknowledge that you will be claiming from the Road Accident Fund, details of this are sent to our appointed Road Accident Fund attorney. 5. If you have your own attorney, then Momentum Medical Scheme’s attorney would liaise with your appointed attorney. 6. If you need an attorney, you can use Momentum Medical Scheme’s attorney. 7. Your attorney will liaise with the Road Accident Fund and settlement will be made to your attorney, who will in turn liaise with us to pay the refund of any medical expenses that the Scheme covered. 8. This process applies to claims for yourself and any of your dependants. Frequently asked questions Q What is considered a third party claim? A When benefits are paid by a third party, eg Road Accident Fund in the case of a motor vehicle accident, or Third Party Insurance in the case of assaults, sports injuries or injuries at school (excluding injuries sustained due to illegal behaviour). Q How long do I have to inform Momentum Medical Scheme of any injury? A You must notify us within 24 hours. Q What if I have future claims pending (eg as a result of a motor vehicle accident) when I join Momentum Medical Scheme? A You need to contact us and forward an undertaking from the Road Accident Fund/other relevant third party to us. Q What happens if I am in a motor vehicle accident and I do not complete the undertaking form? A The signed undertaking is required to finalise the processing of your claim. Claiming from Momentum Medical Scheme Claiming for third party injuries and motor vehicle accidents 14 15 If you are injured on duty, you must report the injury to both Momentum Medical Scheme and your human resources department. Contact us via the web chat facility on momentummedicalscheme.co.za, email us at [e-mail], send us a WhatsApp message or call us on 0860 11 78 59. Information needed when contacting us: — your membership number — the principal member’s surname, initials and first name — the full name(s) of the person(s) injured — the date the injury was sustained — the details of the injury — your employer’s Workmen’s Compensation Fund details, if applicable. The Scheme does not authorise claims that are payable by the Workmen’s Compensation Fund as the hospital follows a different authorisation process for these claims. Please ensure that you have the signed forms from your human resources department at the point of your admission, if the admission is as a result of a Workmen’s Compensation claim. Frequently asked questions Q How long do I have to inform Momentum Medical Scheme of an injury at work? A You must notify us within 24 hours. Important notes Momentum Medical Scheme will provide an authorisation for your treatment, subject to Scheme Rules and available benefits. Please check with your employer if you are entitled to benefits from the Workmen’s Compensation Fund for injuries sustained during the course and scope of your employment. If you are entitled to benefits, Momentum Medical Scheme will only pay for medical expenses not covered by the Workmen’s Compensation Fund. The Workmen’s Compensation Commissioner must supply written proof of the medical expenses that will not be covered by the Workmen’s Compensation Fund, where applicable. You must register on the health management programme to have access to the relevant benefits. To register, you or your doctor can send us a WhatsApp message or call us on 0860 11 78 59. You can also contact us via the web chat facility on momentummedicalscheme.co.za or email us at [e-mail]. 1. The health management consultant will advise you with regard to the programme benefits and requirements to register on the programme. Information needed when contacting us: — your membership number — the name and details of the patient — the diagnosis code (ICD–10 code) — the name and practice number of your treating GP/specialist — details of the treatment and medicine. The health management programmes that we offer include the following: — Cholesterol management — Diabetes management — Hypertension management — Mental health — Oncology management — Chronic renal failure and organ transplant management — Drug and alcohol rehabilitation management — Maternity management — HIV/Aids management. Frequently asked questions Q Why should I register on a health management programme? A These programmes are there to help you with the management of certain medical conditions and to ensure that you understand and actively participate in the management of your condition, together with your treating doctor. Q How do I register for the HIV/Aids benefit? A If you test HIV positive, you will need to register on Momentum Medical Scheme’s HIV/Aids management programme. Please contact the HIV/Aids call centre on 0860 50 60 80 for assistance. Q How do I register on the Maternity management programme? A You can register on the Momentum App or by logging on to momentummedicalscheme.co.za. You can also contact us via the web chat facility on momentummedicalscheme.co.za, email us at [e-mail], send us a WhatsApp message or call us on 0860 11 78 59. Q When should I register on the Maternity management programme? A Between the 8th and 20th week of pregnancy to ensure that you enjoy all the benefits of the Maternity management programme. Please remember to contact us to obtain pre-authorisation for your confinement within 30 days of your delivery date. If your admission date changes, you have 48 hours from the date of admission to notify us. If you would like to make use of the doula (labour coach) benefit, it must be authorised as part of your maternity registration. The doula benefit is available if you are planning to have a natural delivery and your gynaecologist is a Momentum Medical Scheme Associated gynaecologist. Q Does the hospital register my baby with Momentum Medical Scheme? A No, you need to contact us within 30 days of birth to obtain a newborn registration form to register your baby on your membership. If your employer pays your contributions, you need to inform your payroll department. Your employer then needs to provide us with the relevant details. Your contribution for the first month for your newborn is Claiming for injuries at work Registering for a health management programme 16 17 Chronic provider: Any and Associated The Any and Associated chronic provider choice allows you to obtain your out-of-hospital oncology benefits (chemotherapy, radiation, hormone therapy, procedures and consultations), from any registered oncologist, subject to a limit of R300 000 per beneficiary per year. A 20% co-payment applies once this limit is reached. Who needs to register and how? Members diagnosed by an oncologist who need some form of chemotherapy, radiotherapy, hormonal therapy and/or supportive therapy need to register on the oncology programme. 1. To register, you must be seen and assessed by your treating oncologist, who will complete a treatment plan request form. The form is available at your oncologist’s rooms or from our contact centre. 2. The treatment plan form and histology results must be sent to our oncology department via email at [e-mail]. 3. Once received, the oncology disease manager will review the request in accordance with recognised treatment protocols and guidelines for oncology treatment based on clinical appropriateness, evidence-based medicine and your chosen benefit option. If the criteria are met, we will generate an authorisation, and provide a response to you and your treating oncologist. 4. We may need additional information from your oncologist, such as test results, in order to complete the registration process. 5. Your doctor’s rooms should contact you when the treatment date has been established. Frequently asked questions Q What if the prescribed treatment needs to change or additional benefits are required? A Changes, renewals and amendments to your oncology treatment plan must be emailed to the oncology department by your treating oncologist, and are subject to approval and available benefit limits. Important notes Benefits that fall outside the specified dates of the treatment plan, as confirmed with your oncologist, will require further authorisation. You must submit a motivation from your doctor via email to [e-mail]. If your condition requires additional radiology or pathology to that provided via your treatment plan, your doctor needs to notify the oncology department prior to you having these done. For members who still require follow up (non-active treatment) after active treatment is completed, the first 12 months’ treatment will be paid for by Momentum Medical Scheme, in accordance with our clinical protocols and relative legislation requirements. Thereafter, it will be paid from Momentum HealthSaver+ , if available. Chronic provider: State The State chronic provider allows you to obtain your out-of-hospital oncology benefits (chemotherapy, radiation, hormone therapy, procedures and consultations), from an oncologist authorised by us, subject to a limit of R300 000 per beneficiary per year. A 20% co-payment applies once this limit is reached. If you choose to obtain your oncology benefits from a nonauthorised provider, you will be liable to pay 20% of the accounts for all oncology benefits, including pathology, radiology, medication and other related benefits and services. Who needs to register and how? Members diagnosed by an oncologist who need some form of chemotherapy, radiotherapy, hormonal therapy and/or supportive therapy need to register on the oncology programme. 1. To register, you must be seen and assessed by your treating oncologist, who will complete a treatment plan request form. The form is available at your oncologist’s rooms or from our contact centre. 2. The treatment plan form and histology results must be sent to our oncology department via email at [e-mail]. 3. Once received, the oncology disease manager will review the request in accordance with recognised treatment protocols and guidelines for oncology treatment based on clinical appropriateness, evidence-based medicine and your chosen benefit option. If the criteria are met, we will generate an authorisation, and provide a response to you and your treating oncologist. 4. We may need additional information from your oncologist, such as test results, in order to complete the registration process. 5. Your doctor’s rooms should contact you when the treatment date has been established. Frequently asked questions Q What if the prescribed treatment needs to change or additional benefits are required? A Changes, renewals and amendments to your oncology treatment plan must be emailed to the oncology department by your treating oncologist, and are subject to approval and available benefit limits. Q Where can I obtain a list of the Momentum Medical Scheme authorised oncologists? A The list is available on momentummedicalscheme.co.za or you can contact us via the web chat facility on momentummedicalscheme.co.za, email us at [e-mail], send us a WhatsApp message or call us on 0860 11 78 59. Our contact centre consultant can then verify whether your oncologist is an authorised provider or provide you with details of the Momentum Medical Scheme authorised oncologists. Q What happens if my treating oncologist is not a Momentum Medical Scheme authorised oncologist? A If you choose to obtain your oncology benefits from a non-authorised provider, you will be liable to pay 20% of the accounts for all oncology benefits, including pathology, radiology, medication and other related benefits and services. Important notes Benefits that fall outside the specified dates of the treatment plan, as confirmed with your oncologist, will require further authorisation. You must submit a motivation from your doctor via email to [e-mail]. If your condition requires radiology or pathology tests in addition to that provided on your treatment plan, your doctor needs to notify the oncology department before you go for the radiology or pathology tests. For members who still need follow up (non-active treatment) after active treatment is completed, the first 12 months’ treatment will be paid by Momentum Medical Scheme in accordance with our clinical protocols and relative legislation requirements. Thereafter, it will be paid from Momentum HealthSaver+, if available. + Momentum HealthSaver is a complementary product available from Momentum Registering for oncology benefits 18 19 Frequently asked questions Q How do I prove my Momentum Medical Scheme membership? A Show your printed or digital membership card when you visit a healthcare provider. You can access your digital membership card on the Momentum App. Q Who may I register as a dependant? A You can register the following dependants, subject to underwriting: – your spouse by law or custom – the life partner you have committed to and with whom you share a common household – your own, step or legally adopted children under the age of 21. We need proof of dependency for dependants (excluding spouse) who are over the age of 21. The adult contribution rate applies to all dependants from the age of 21 – members of your immediate family for whom you are liable for family care and support. We need proof of these relationships and dependency. Q Which changes to membership details do I have to submit to Momentum Medical Scheme? A You need to let us know in the case of: – a change in your marital status – the birth or legal adoption of a child, if you are adding the child to your membership – any dependant who is no longer eligible for membership – any changes to your or your adult dependants’ address or contact details – removing or adding dependants on your membership – changes to your bank account details (you need to complete and send us a Changes to bank details form, together with a copy of your ID). Q How do I add a dependant? A Complete an Addition of Dependants form. If your employer pays your contributions, you need to inform your payroll department of any additions of dependants on your membership. Your employer then needs to provide us with these details. Q How do I withdraw a dependant? A Complete a Changes to membership details form, providing one calendar month’s written notice. If your employer pays your contributions, you need to inform your payroll department of any withdrawals of dependants on your membership. Your employer then needs to provide us with these details. Q What if I resign or retire and I have been a member through my employer and wish to remain on Momentum Medical Scheme? A Complete a Continuation of Membership form. You may continue your membership when you resign, retire, go on early retirement or retire due to ill health or other disabilities. When your employer terminates the entire company’s membership, however, you will no longer be eligible to remain on Momentum Medical Scheme. Q What happens to beneficiaries when the principal member passes away? A Remaining beneficiaries must contact us to inform Momentum Medical Scheme of the death of the principal member. Dependants can choose to remain members of Momentum Medical Scheme and need to complete a Continuation of Membership form. Q When does membership terminate? A You may resign from Momentum Medical Scheme by giving one calendar month’s written notice. Complete a Termination of Membership form. If you belong to Momentum Medical Scheme through your employer, they have to notify us by giving one calendar month’s written notice. We will terminate your membership if you or your employer fail to pay outstanding amounts due to us, if we get confirmation that you and/or your dependants committed fraud or we find that you have not disclosed relevant and material information, ie non-disclosure. Q Where do I obtain the relevant form if I need to make changes to my membership? A Speak to your healthcare adviser, contact us via the web chat facility on momentummedicalscheme.co.za, email us at [e-mail], send us a WhatsApp message or call us on 0860 11 78 59. Q What do I do if I lose my membership card? A Access your digital membership card on the Momentum App or order a new printed card online by logging on to momentummedicalscheme.co.za. You may also contact us via the web chat facility on momentummedicalscheme.co.za, email us at [e-mail], send us a WhatsApp message or call us on 0860 11 78 59. Q What should I do when travelling abroad to access my international emergency cover benefit? A It is mandatory for all members to pre-notify for travel to any international destination in order to have access to the international emergency cover benefit. In addition to pre-notification, you must arrange for your treating doctor in South Africa to complete a fit to travel questionnaire, confirming the doctor is comfortable for you to travel, if you: – have been hospitalised in the 2 months prior to travel – are registered on any of the health management programmes; including the chronic diseases, oncology and organ transplant management programmes – are older than 70 years – are pregnant – have an underlying illness, such as diabetes, hypertension or cardiovascular conditions – have an immune-suppressive condition – have any chronic respiratory diseases/conditions. As part of Momentum Medical Scheme’s ongoing managed care principles, the Scheme does not deem it appropriate for beneficiaries who are on active oncology treatment, dependent on home oxygen, or on chronic renal dialysis, to travel, and therefore these beneficiaries will not be authorised for any international emergency cover benefits related to these conditions, even if the treatment is deemed an emergency and the member obtained a fit to travel confirmation. The same applies to maternity benefits and treatment, including childbirth. Please refer to the full list of exclusions related to this benefit outlined in the Travel policy wording. The fit to travel confirmation is valid for a period of 60 days. If you submit the questionnaire more than 60 days prior to your departure, you will need to provide us with an updated fit to travel confirmation within 60 days of your departure date. If you are uncertain whether you or your dependants need to obtain a fit to travel confirmation, or if you need any further information, contact us via the web chat facility on momentummedicalscheme.co.za, email us at [e-mail], send us a WhatsApp message or call us on 0860 11 78 59. Q What should I do if I need emergency treatment when travelling abroad? A Should you need emergency medical, dental, or optical treatment relating to an accidental injury or emergency illness while travelling abroad: – phone the emergency medical assistance helpline on [phone] (reverse call charges are accepted) – our preferred provider will coordinate your emergency benefits including emergency transport and evacuation where applicable, on behalf of Momentum Medical Scheme and will settle emergency medical expenses incurred whilst travelling abroad directly with the provider of service, provided that the necessary authorisation has been obtained – email claims for reimbursement of emergency medical and dental expenses paid by the beneficiary, together with any supporting documentation and authorisation details, to [e-mail] – a R2 180 co-payment applies per out-patient claim paid by the Scheme. Membership 20 21 Momentum Medical Scheme is committed to ensuring that the interests of our members are protected at all times. This includes providing appropriate and adequate systems and processes to make sure we settle your claims timeously and provide a prompt response to any queries, complaints and disputes you may have. As the first point of call for a query, you may contact us via the web chat facility on momentummedicalscheme.co.za, email us at [e-mail], send us a WhatsApp message or call us on 0860 11 78 59. If your query is not resolved satisfactorily, you may request that your query be escalated to the respective manager for intervention or resolution. If you are still not satisfied with the intervention or resolution, you may lodge a formal complaint or dispute, either in writing or by phoning our dedicated toll-free complaints number on 0800 20 40 70 (available from 08:00 to 16:30, Mondays to Fridays), or you may request our contact centre or correspondence consultant to provide you with the details of the process to be followed in order to have your query, complaint or dispute reviewed by Momentum Medical Scheme. It is essential that you follow the complaints process as outlined above to ensure that your query is timeously and efficiently resolved by Momentum Medical Scheme. An aggrieved member does, however, have the right to lodge a complaint against a decision of Momentum Medical Scheme, with the Council for Medical Schemes (CMS). The CMS governs the medical schemes industry and therefore your complaint should be related to your medical aid. Any beneficiary who is aggrieved with the conduct of a medical scheme can submit a complaint. It is important to note that you should always first seek to resolve your complaints through the complaints processes in place at Momentum Medical Scheme, before approaching the CMS for assistance. The CMS protects and informs members and the public about their medical scheme rights and obligations, ensuring complaints raised are handled appropriately. You can send your complaint in writing to the CMS via email at [e-mail]. You can also call the CMS on 0861 12 32 67 or visit medicalschemes.co.za for more information and for the necessary forms that will need to be completed. The CMS should send you written acknowledgement of your complaint within 3 working days of receiving it and will provide the reference number and contact details of the person who will be handling your complaint. In terms of Section 47 of the Medical Schemes Act 131 of 1998, a written complaint received in relation to any matter provided for in this Act will be referred to the medical scheme. The medical scheme is obliged to respond to CMS in writing within 30 days. * These are examples of medication not covered Complaints procedure 26 conditions are covered according to the Chronic Disease List in the Prescribed Minimum Benefits. Chronic conditions — Cardiovascular Cardiac dysrhythmias, Cardiac failure, Cardiomyopathy, Coronary artery disease, Hyperlipidaemia, Hypertension — Dermatology/Skin disorder Systemic lupus erythematosus — Endocrine Addison’s disease, Diabetes insipidus, Diabetes mellitus Type 1, Diabetes mellitus Type 2, Hypothyroidism — Gastro-intestinal Crohn’s disease (excluding biologicals such as Revellex*), Ulcerative colitis — Haematology Haemophilia — Musculo-skeletal Rheumatoid arthritis (excluding biologicals such as Revellex* and Enbrel*) — Neurology Multiple sclerosis (excluding biologicals such as Avonex*, subject to protocols), Epilepsy, Parkinson’s disease — Ophthalmology Glaucoma — Psychiatric Schizophrenia, Bipolar mood disorder — Renal Chronic renal disease — Respiratory Asthma, Chronic obstructive pulmonary disease, Bronchiectasis Digital access: Web and app Log in to momentummedicalscheme.co.za to view your benefit information, claims statements and claims history, and search for healthcare providers in your area. If your contact details have changed, you can update your postal address, contact numbers and email address. 1. Go to momentummedicalscheme.co.za and select Login. 2. Type your username and password. Frequently asked questions Q How do I get a username and password? A You need to register online at momentummedicalscheme.co.za. Select Register and follow the online process. Get access to information at your fingertips Download the Momentum App for instant access to: — viewing your digital membership card, — your Momentum Medical Scheme benefit information, — viewing your claims history, — submitting your claims, — requesting authorisations for hospital admissions and procedures, — obtaining your travel and tax certificates, — registering on the maternity programme, and more. 22 23 The following list is a guideline of the procedures/treatment covered from the Major Medical Benefit, irrespective of whether the procedure is performed in- or out-of-hospital. Pre-authorisation is required, regardless of where the procedure is performed. It is important to note that this is not the complete list of all the procedures covered by Momentum Medical Scheme. Should you need clarity on whether a procedure is covered, please contact us to confirm. — Cardiovascular 24-hour Holter ECG, Blood transfusions, Carotid angiograms, Coronary angiogram, Coronary angioplasty, Plasmapheresis — ENT Antroscopies, Direct laryngoscopy, Grommets, Myringotomy, Nasal cautery, Nasal scans and surgery, Functional nasal and sinus surgery, Tonsillectomy — General procedures and treatment Biopsy of breast lump, Drainage of subcutaneous abscess, Removal of extensive skin lesions, Removal of minor skin lesions, Laparoscopy, Lymph node biopsy, Nail surgery, Open hernia repairs, Superficial foreign body removal, Treatment of headache — Gastro-intestinal Colonoscopy, ERCP, Gastroscopy, Oesophagoscopy, Sigmoidoscopy — Gynaecology Cervical laser ablation, Colposcopy, Cone biopsy, Dilatation and curettage, Hysteroscopy, Incision and drainage of Bartholin’s cyst, Marsupialisation of Bartholin’s cyst, Tubal Ligation — Neurology 48-hour Holter EEG, Electro-convulsive therapy, Hyperbaric oxygen treatment for decompression sickness, Myelogram — Obstetrics Childbirth in non-hospital, Amniocentesis — Oncology Chemotherapy, Radiotherapy, Hyperbaric oxygen for radiation necrosis — Ophthalmology Cataract removal, Meibomian cyst excision, Pterygium removal, Trabeculectomy, Treatment of diseases of the conjunctiva — Orthopaedic Arthroscopy, Back and neck surgery, Bunionectomy, Carpal tunnel release, Conservative back and neck treatment, Ganglion surgery, Joint replacements — Renal Dialysis — Respiratory Bronchography, Bronchoscopy, Treatment of adult influenza, Treatment of adult respiratory tract infections — Urology Cystoscopy, Prostate biopsy, Vasectomy — Anorectal procedures Procedure for haemorrhoids, fissure and fistula — Incision and drainage of abscess and/or cyst Skin (deep/non-superficial lesions), subcutaneous tissue and pilonidal 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 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. Specialised procedures/treatment Exclusions Important notes The costs of anaesthetists for gastroscopies and colonoscopies are covered up to R620, subject to pre-authorisation. For all other out-patient procedures, the costs of anaesthetists (if any) are only covered if approved by Momentum Medical Scheme. 24 25 List of Associated hospitals Eastern Cape Beacon Bay - East London Life Beacon Bay Hospital East London Life East London Private Hospital Gqeberha Hunterscraig Psychiatric Hospital New Mercantile Hospital St Georges Hospital Humansdorp Isivivana Private Hospital Queenstown Queenstown Private Hospital Southernwood - East London St. Dominic’s Hospital Life St James Hospital St Marks Clinic Uitenhage Netcare Cuyler Hospital Umtata St Mary’s Private Hospital Free State Bethlehem Mediclinic Hoogland Bloemfontein Bloemfontein Eye Hospital Mediclinic Bloemfontein Pasteur Hospital Fichardtpark - Bloemfontein Rosepark Hospital Welkom Mediclinic Welkom Gauteng Arcadia - Pretoria Muelmed Hospital Pretoria Heart Hospital Bedfordview - Johannesburg Bedford Gardens Private Hospital Benoni Glynnview Hospital The Glynnwood Birchleigh - Johannesburg Birchmed Day Clinic Brakpan Dalview Clinic Brooklyn - Pretoria Brooklyn Surgical Centre Bryanston - Johannesburg Mediclinic Sandton Constantia Kloof – Johannesburg Mayo Clinic Die Wilgers - Pretoria Wilgers Hospital Erasmuskloof - Pretoria Kloof Hospital Faerie Glen - Pretoria Faerie Glen Hospital Florida – Johannesburg Flora Clinic Fourways Fourways Hospital Groenkloof - Pretoria Groenkloof Hospital Gauteng (continued) Heidelberg Suikerbosrand Clinic Helderkruin - Johannesburg Medgate Day Clinic Kensington - Johannesburg New Kensington Clinic Les Marais - Pretoria Eugene Marais Hospital Mabopane - Pretoria Legae Private Clinic Midrand Carstenhof Clinic Midstream Mediclinic Midstream Morningside - Johannesburg Mediclinic Morningside Nietgedacht - Johannesburg Riverfield Lodge Parktown - Johannesburg The Donald Gordon Brenthurst Clinic Nelson Mandela Children’s Hospital Pretoria North Pretoria North Surgical Centre Primrose - Johannesburg Roseacres Clinic Randfontein Robinson Hospital Roodepoort Wilgeheuwel Hospital Springs Springs Parkland Clinic St Mary’s Womens Clinic Sunnyside - Pretoria Medforum Hospital Vanderbijlpark Mediclinic Emfuleni Vereeniging Mediclinic Vereeniging Kwazulu-Natal Amanzimtoti Kingsway Hospital Berea - Durban Entabeni Hospital Chatsworth - Durban Chatsmed Garden Hospital Durban City Hospital Empangeni Life Empangeni Private Hospital Hillcrest - Durban Hillcrest Private Hospital Hilton - Pietermaritzburg Hilton Private Hospital Howick Lenmed Howick Private Hospital Isipingo Isipingo Hospital Margate Netcare Margate Hospital Newcastle Newcastle Private Hospital Kwazulu-Natal (continued) Newlands East – Durban Ethekwini Hospital Phoenix - Durban Mount Edgecombe Hospital Pietermaritzburg Midlands Medical Centre Mediclinic Pietermaritzburg Pinetown The Crompton Hospital Port Shepstone Hibiscus Hospital Richards Bay Netcare The Bay Hospital Tongaat Victoria Hospital uMhlanga Gateway Hospital Netcare uMhlanga Hospital Westville - Durban Westville Hospital Limpopo Lephalale Mediclinic Lephalale Makhado Crestcare Zoutpansberg Private Hospital Polokwane Mediclinic Limpopo Thabazimbi Mediclinic Thabazimbi Tzaneen Mediclinic Tzaneen Mpumalanga Emalahleni Cosmos Hospital Ermelo Mediclinic Ermelo Mbombela Lowveld Hospital Mediclinic Nelspruit Middelburg Midmed Hospital Piet Retief Piet Retief Hospital Trichardt Mediclinic Highveld North West Brits Mediclinic Brits Klerksdorp Anncron Clinic Potchefstroom Mediclinic Potchefstroom Rustenburg Peglerae Hospital Vryburg Vryburg Private Hospital Northern Cape Kathu Kathu Private Hospital Kimberley Mediclinic Kimberley Upington Mediclinic Upington Western Cape Bellville - Cape Town Melomed Bellville Mediclinic Louis Leipoldt Brackenfell Mediclinic Cape Gate Claremont - Cape Town Peninsula Eye Hospital Kingsbury Hospital Durbanville - Cape Town Mediclinic Durbanville Gatesville - Cape Town Melomed Gatesville George Geneva Clinic Mediclinic George Hermanus Mediclinic Hermanus Knysna Knysna Private Hospital Milnerton - Cape Town Mediclinic Milnerton Mitchells Plain - Cape Town Melomed Mitchells Plain Mossel Bay Bayview Hospital Oranjezicht - Cape Town Mediclinic Cape Town Oudtshoorn Mediclinic Klein Karoo Paarl Mediclinic Paarl Panorama - Cape Town Mediclinic Panorama Pinelands - Cape Town Vincent Pallotti Hospital Plettenberg Bay Mediclinic Plettenberg Bay Plumstead Mediclinic Constantiaberg Rondebosch Sport Science Orthopaedic Surgical Day Centre Somerset West Mediclinic Vergelegen Stellenbosch Mediclinic Stellenbosch Mediclinic Winelands Tokai Melomed Tokai Vredenburg West Coast Private Hospital Worcester Mediclinic Worcester This hospital list is subject to change. View the latest information as well as a list of day hospitals on the Momentum App or momentummedicalscheme.co.za. 26 27 1. Chronic Disease List is a list of 26 chronic conditions for which all medical schemes in South Africa have to provide cover in terms of the Medical Schemes Act 131 of 1998. 2. Clinical protocol: Momentum Medical Scheme uses evidence-based treatment principles, called clinical protocols, to determine and manage benefits for specific conditions. 3. Clinically appropriate: Treatment that is in line with the clinical protocols (see definition above) for your condition. 4. Co-payment: This is an amount that you need to pay towards medical procedures and treatments. The amount payable may vary depending on the type of procedure or treatment, and where the procedure or treatment is performed. If the co-payment amount is higher than the amount charged by the healthcare provider, you will have to pay for the cost of the procedure or treatment. A co-payment will not apply in the event of an emergency medical condition. 5. Designated service providers: Momentum Medical Scheme uses a network of Designated Service Providers, such as Associated GPs and Specialists, as well as State facilities, depending on the circumstances, to diagnose and treat you for the Prescribed Minimum Benefits. See definition of Prescribed Minimum Benefits under point 15 for more information. 6. Emergency medical condition means the sudden and, at the time, unexpected onset of a health condition that requires immediate medical or surgical treatment, where failure to provide medical or surgical treatment would result in serious impairment to bodily functions or serious dysfunction of a bodily organ or part, or would place the person’s life in serious jeopardy. 7. Formulary: A formulary is a list of medicines covered on your option, from which a doctor can prescribe appropriate medicine for your chronic condition. 8. Hospitals: a. Acute hospital: A hospital that provides inpatient medical care and other related services for surgery, acute medical conditions or injuries, and which is permitted to provide treatment that includes part of an overnight stay at the facility. b. Day hospital: A healthcare facility which focuses on the provision of short-stay surgical and diagnostic procedures, performed in an operating theatre on a same-day basis. The patient is admitted in the morning and discharged on the same day. 9. Momentum Medical Scheme Rate: Every year Momentum Medical Scheme negotiates with medical care providers to determine the amount the Scheme will pay per treatment. This is called the Momentum Medical Scheme Rate. On the Custom Option, the Scheme pays 100% of the Momentum Medical Scheme Rate, which means the Scheme will pay up to the amount agreed for the treatment. Where doctors charge more than the agreed upon rate for the treatment, you may need to pay the difference. 10. Momentum Medical Scheme Reference Price is the maximum rand value that Momentum Medical Scheme will pay for a medicine from a group of similar medicines. This amount is proportional to the cost of the maximum dose of the reference price medicines that are included in the group of similar medicines. If you choose to use medication that is not within the reference pricing, you will need to pay for the difference in cost between the medicine you chose and the reference price. 11. Out-of-hospital procedures: These are procedures that are not performed in a hospital. For example, they could be performed in your doctor’s rooms or an outpatient facility. 12. Out-patient facility: A treatment centre where medical procedures can be done without the patient being admitted to hospital. 13. Pre-authorisation: Pre-authorisation is when you contact the Scheme to let us know you are about to receive medical treatment. The Scheme will confirm whether you are covered for the expected treatment, and at what rate your option covers such treatment. You will receive a pre-authorisation number which you need to provide to the doctor. While pre-authorisation is not a guarantee that your treatment will be covered, it gives you the peace of mind that benefits will be paid in line with Scheme Rules, your option and membership status. 14. Pre-notification: Pre-notification is when you contact us to let us know that you are about to use a Health Platform benefit, such as your annual dentistry checkup. 15. Prescribed Minimum Benefits (PMBs) is a list of benefits for which all medical schemes in South Africa have to provide cover in terms of the Medical Schemes Act 131 of 1998 and the Regulations thereto. In order to access these benefits: • Your medical condition must qualify for cover and be part of the defined list of Prescribed Minimum Benefit conditions. • The treatment needed must match the treatments in the defined benefits. • You must use the Scheme’s Designated Service Providers. See the definition of Designated Service Providers under point 5 for more information. If you voluntarily choose to use non-designated service providers, the Scheme will pay benefits up to the Momentum Medical Scheme Rate and relevant copayments will apply. If you use non-designated service providers in cases of an emergency medical condition, it is deemed involuntary and co-payments are therefore waived. If your medical condition and treatment do not meet the above criteria to access these benefits, we will pay according to the benefits on your chosen benefit option. 16. Provider definitions: a. Associated providers, eg hospitals and GPs: These are providers that Momentum Medical Scheme has negotiated agreements with. You pay a lower contribution by selecting to use Associated hospitals and doctors. If you do not use the provider you have chosen, a co-payment will apply. b. Associated specialists: Momentum Medical Scheme has negotiated agreements with Associated specialists. In-hospital accounts for Associated specialists are covered in full. c. Preferred Providers: Momentum Medical Scheme has agreements in place with certain providers of healthcare services, which we refer to as preferred providers. You need to use preferred providers for certain benefits. Preferred providers are not the same as Designated Service Providers, which are used for the provision of Prescribed Minimum Benefits. d. State: State hospitals are public facilities. You pay a lower contribution by selecting State as your Chronic Benefit provider. 17. Sub-limit: A sub-limit is a limit that applies in addition to the overall limit on a specific benefit. Glossary of terms contained in this brochure 28 Version 2025_1 Get access to information at your fingertips Download the Momentum App for instant access to: — viewing your digital membership card, — your Momentum Medical Scheme benefit information, — viewing your claims history, — submitting your claims, — requesting authorisations for hospital admissions and procedures, — registering on the maternity programme, and more. Contact us WhatsApp [phone] Web chat Log in to momentummedicalscheme.co.za and click on the chat button Emergency 082 911 South Africa medical [phone] International transport momentummedicalscheme.co.za Virtual help Visit momentummedicalscheme.co.za, click on “Contact us” and then on “Click here to join a virtual help session” for one of our consultants to assist you digitally Claims [e-mail] Queries [e-mail] Fraud hotline [phone] [e-mail] If you suspect that fraud or abuse has occurred, or you have become aware of potential fraud or abuse that may affect Momentum Medical Scheme, please contact the toll-free fraud hotline anonymously. This service is managed by a third party and the caller’s identity is fully protected. Physical and postal address 201 uMhlanga Ridge Boulevard Cornubia 4339 PO Box 2338 Durban 4000 South Africa Council for Medical Schemes Customer Care Centre 0861 123 267 [e-mail] medicalschemes.co.za