Get well soon card and a vase of flowers on a table next to a blood pressure monitor at a hospital.

Major Medical Benefit

To ensure that you’re covered for more than just an occasional visit to your local GP, the Major Medical Benefit gives you plan-specific benefits that cover you in full in the event that you’re hospitalised or required to go through surgery.

What does it cover?

With this cover, your hospital accounts and costs related to your stay in a hospital, as well as certain procedures performed both in- or out-of-hospital, are paid for at the agreed rate, subject to pre-authorisation.

The following is an overview of the cover provided across our six medical aid options.

Ingwe Option

Cover

Hospital accounts are covered in full at the rate agreed with the hospital group.

Specialists are covered up to 100% of the Momentum Health Rate.

No annual limit applies.

Hospital Provider

Any hospital, Ingwe Network or
State hospitals.

Impact Option

Cover

Hospital accounts are covered in full at the rate agreed with the hospital group.

Specialists are covered up to 100% of the Momentum Health Rate.

No annual limit applies.

Hospital Provider

Impact Network hospitals.

Custom Option

Cover

Hospital accounts are covered in full at the rate agreed with the hospital group.

Specialists are covered up to 100% of the Momentum Health Rate. A R1 500 co-payment per authorisation applies, except for car accidents, maternity confinements, and emergency treatment.

No annual limit applies.

Hospital Provider

Any or Associated hospitals.

Incentive Option

Cover

Hospital accounts are covered in full at the rate agreed with the hospital group.

Specialists are covered up to 200% of the Momentum Health Rate. Co-payments may apply for certain specialised procedures or treatment.

No annual limit applies.

Hospital Provider

Any or Associated hospitals.

Extender Option

Cover

Hospital accounts are covered in full at the rate agreed with the hospital group.

Specialists are covered up to 200% of the Momentum Health Rate. Co-payments may apply for certain specialised procedures or treatment.

No annual limit applies.

Hospital Provider

Any or Associated hospitals.

Summit Option

Cover

Hospital accounts are covered in full at the rate agreed with the hospital group.

Specialists are covered up to 300% of the Momentum Health Rate.

No annual limit applies.

Hospital Provider

Any hospital

For more information about hospitalisation and specialised procedures covered under the Major Medical Benefit, have a look at the focus page or your chosen medical aid option to see what you’re covered for.

How to get pre-authorisation

You get pre-authorisation once benefits have been verified and Scheme Rules and protocols have been applied. If the hospital or doctor obtains the authorisation on your behalf, you need to verify whether or not you will need to pay any co-payments or shortfalls as a result of not using a Designated Service Provider, or resulting from benefit limits or protocols.

Follow these steps to get pre-authorisation:

Step 1

Phone our member call centre on 0860 117 859

Step 2

Make a note of the authorisation number

Step 3

Give the authorisation number to your provider

When you phone the pre-authorisation call centre, make sure you have the following information available:

Your membership number.
The name and details of the patient.
The reason for hospital admission, procedure/treatment, MRI or CT 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 or day clinic.

Important to know

Am I responsible for obtaining pre-authorisation?

You are responsible for obtaining pre-authorisation from Momentum Health at least 48 hours before you and/or your dependents are admitted to a hospital or day clinic, receive specialised treatment covered under the Specialised Procedures/Treatment benefit, or have MRI and CT scans.

What happens if I don't get a pre-authorisation for a procedure?

If authorisation is not obtained, a 30% co-payment will apply on all accounts related to the event and the Scheme will cover 70% of the negotiated tariff, provided authorisation would have been granted according to the Rules and protocols of the Scheme.

What happens in the case of an emergency?

In the case of an emergency, you, a family member or a friend may obtain authorisation within 72 hours of admittance.

What happens if I don't choose a network hospital?

Ingwe Option: Members who choose Ingwe Network hospitals and do not use this provider will have a co-payment of 30% on the hospital account. Members who choose State hospitals and do not use this provider will have a co-payment. This co-payment will be the difference in the cost between state facility charges and the amount charged by the provider they use.
Impact Option: Members who do not use Impact Network hospitals will have a 30% co-payment on their hospital account.
Custom, Incentive and Extender Options: Members who choose Associated hospitals and do not use them, will be liable for a 30% co-payment on their hospital account.