Medical aid frequently asked questions

Out-of-pocket expenses

How can I avoid out-of-pocket expenses?

There are a few ways you can avoid out-of-pocket expenses:

If you have chosen to make use of a network provider, such as hospitals or doctors, be sure not to use non-network providers.
Always use a designated pharmacy for your prescribed medication.
For over-the-counter medicines, use your HealthSaver funds (depending on medical aid option selected and available funds in the account) or your Multiply Visa Card
If pre-approval is required for certain doctors or specialists visits, make sure you get the authorisation code before your appointment.

Emergencies

What is classified as a medical emergency?

An 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.

What happens if I am in an accident, rendered unconscious, and taken to a hospital that is not on my medical aid’s designated service provider (DSP) list?

You will be stabilised first at a hospital that is the closest and then transported to the nearest hospital as per the DSP listed on your Momentum medical aid option. This will not apply if you have selected Any hospital provider.

What is the benefit of registering onto the Managed Healthcare programmes such as maternity programme, chronic illness, and oncology?

The benefits of a healthcare programme are numerous, from being provided with a treatment plan that includes cover for visits to doctors and specialists and other service providers that provide the treatment you need for your diabetes, to investigations, such as pathology tests, which are necessary to manage your condition and many other additional benefits that are considered medically necessary by your doctor. If you need to be hospitalised, we will allocate a case manager to follow up regarding your hospital stay. In the case of chronic conditions, a chronic medicine consultant will liaise with your doctor regarding your treatment.

What is a waiting period and how does it work?

In terms of the Medical Schemes Act, medical schemes may apply waiting periods to new members joining the Scheme.

If a three-month general waiting period is applied, this means that you have to wait three months from the date that your membership commences before you can claim from your Momentum Health benefits. Should you qualify for the Prescribed Minimum Benefits, you would be eligible to obtain treatment at a State facility, provided that the condition is one that is covered by the Prescribed Minimum Benefits. A list of the Prescribed Minimum Benefits is available on www.medicalschemes.com

Self-payment gap

What is a self-payment gap?

A self-payment gap is when you have used up all your medical savings and then need to fund your health expenses from your own pocket.

For example, let’s say you have R3 000 to use on day-to-day medical expenses for the year. If you use up this amount, you move into the self-payment gap territory. This self-payment gap varies according to your family size. The more dependants you have, the bigger the self-payment gap. But, it also takes longer to get there, as your contributions would be higher than those of a single member.

Once you have reached your threshold, you move into the above-threshold benefits where the medical scheme pays for your everyday medical expenses. This is only applicable on our Extender Option.

Will the Scheme still pay for chronic medication and hospitalisation when I am in the self-payment gap?

Yes, the Scheme will still cover chronic medication and hospitalisation.

Do I still submit claims when I am in the self-payment gap?

Yes, it is important to continue submitting your claims, otherwise we will not know that you have passed the self-payment gap and qualify for the above-threshold benefits.

Medical scheme membership

Can a medical scheme terminate my membership?

Yes, but only if you belong to a closed medical scheme and you are retrenched, or made redundant, or you resign from the company. An open scheme can only terminate your membership if you do not pay your contributions, or if there was fraudulent transactions or claims.

If I resign from the scheme, until when can I claim?

You can submit claims for medical treatment up until the day your medical scheme membership expires. If you gave written notice of your intention to end your membership on the 31^st of December, and you go to the doctor on that day, you can still submit a claim for that doctor's visit. Anything after midnight that date will not be processed.

Can a person belong to more than one medical scheme?

No, as that is not legal. Claiming twice for the same medical expenses is seen as fraud. It is important to make sure when you are moving medical aids that you terminate your membership with the current medical scheme before you become a member of the new medical scheme.

General

How do I select the option that’s best for me?

You can either speak to a financial adviser, or contact various schemes to get more information before you make your choice. Assess your needs first so that you can choose the option that will give you the best coverage for your needs. For example, if you have eye problems, you won't choose a scheme that only allocates R200 per year for glasses. If you're fairly healthy and don’t get sick very often, it would be beneficial to choose a scheme with low day-to-day benefits, but good hospital coverage. Make sure to read the fine print.

What is a Medical Savings Account?

Usually, a couple options from a medical scheme have a medical savings account or MSA. This is a percentage of your monthly contribution, up to a maximum of 25%. This is used to pay for day-to-day medical expenses. Certain sub-limits still apply. When your MSA is depleted, you will need to pay for your day-to-day medical expenses out of your own pocket.

It is important to note that chronic medication and hospitalisation costs are not paid out from your MSA. Funds in the MSA that is not utilised, is carried over to the next year. Should you resign from the scheme and you still have funds in the MSA, this will be paid out to you.

Momentum App

How can the App assist me?

Download the Momentum App so that you can:

Find a network hospital.
Find an associated provider.
Submit and track your claims.
Get pre-authorisation for Health Platform Benefits.
Check your balances for HealthSaver, Personal Medical Savings Account, HealthReturns, and Active Dayz.
Calculate your HealthReturns.
Get your own statements and tax certificates.
Book a health or fitness assessment.