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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 to use providers that are on the network.
  • 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 Money Card
  • If pre-approval is required for certain doctors or specialists visits, make sure you get the authorisation number 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 Network hospital list?

You will be stabilised first at a hospital that is the closest and then transported to the nearest hospital on your Network hospital list. This will not apply if you have selected Any hospital provider.
What is the benefit of registering on health management programmes such as maternity, chronic illness, and oncology programmes?

The benefits of a health management programme are numerous, from providing a treatment plan that includes cover for visits to doctors and specialists and other service providers for the treatment you need for your condition, to investigations, such as pathology tests, which are necessary to manage your condition and many other additional benefits for treatment that is 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 benefit 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 Medical Scheme benefits.

A 12-month waiting period may also be applied to specific medical conditions. If this waiting period is applied, you will have to wait 12 months from the date your Momentum Medical Scheme membership starts before you can claim benefits for the condition.

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-funding gap

What is a self-funding gap?

This is only applicable on our Extender Option. A self-funding gap is when you have used up all your medical savings and then need to fund your health expenses from your own pocket until you reach the Threshold.

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-funding gap territory. This self-funding gap varies according to your family size. The more dependants you have, the bigger the self-funding gap.

Once you have reached the Threshold, you move into the Extended Cover benefits where the medical scheme pays for your everyday medical expenses.
Do I still submit claims when I am in the self-funding gap?

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

Medical scheme membership

Can Momentum Medical Scheme terminate my membership?

Yes, Momentum Medical Scheme will 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 31st 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?

Some medical scheme options have a medical savings account. 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 may still apply.

On the Incentive Option, 10% of your contribution is available in a savings account. When your Savings is depleted, you will need to pay for your day-to-day medical expenses out of your own pocket. On the Extender Option, 25% of your contribution is available in a savings account to cover day-to-day expenses. If this component is not enough to cover your annual day-to-day expenses, you will also have access to the Extended Cover benefit which provides further cover for day-to-day benefits once your day-to-day claims have reached the Threshold (a pre-determined amount that is based on your family size).

It is important to note that chronic and hospitalisation benefits are not paid from your savings. Funds in the savings account that are not utilised, are carried over to the next year. Should you resign from the scheme and you still have funds in your savings account, 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.
  • View your claims history and get your claim statements.
  • Pre-notify for Health Platform Benefits and get pre-authorisation for hospital admissions.
  • Check your balances for HealthSaver+, Personal Medical Savings Account, HealthReturns+, and Active DayzTM
  • Calculate your HealthReturns+.
  • Book a health or fitness assessment.
  • • Download and share your health tax certificates.

+ You may choose to make use of additional products available from Momentum Metropolitan Holdings Limited (Momentum), to seamlessly enhance your medical aid. Momentum is not a medical scheme and is a separate entity to Momentum Medical Scheme. The complementary products are not medical scheme benefits. You may be a member of Momentum Medical Scheme without taking any of the complementary products.

Learn more about medical aid

How to make the
most of your benefits

How to submit
a claim

How to get pre-authorisation

Download the
Momentum App

Contact Momentum Medical Scheme

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