Medical aid frequently asked questions

Yes, Momentum Medical Scheme will terminate your membership if you do not pay your contributions or if we get confirmation that you or your dependants have committed fraud.

You can submit claims for medical treatment up until the day your medical scheme membership expires. If you have given 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 on that date will not be processed.

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 your membership of the new medical scheme starts.

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

• If you have chosen to use a network provider, such as hospitals or doctors, be sure to use providers on the network.

• Always use a contracted pharmacy for your prescribed medication.

• For over-the-counter medicines, you can use Momentum’s HealthSaver⁺ account, which lets you make provision for healthcare expenses not covered on your option.

• If pre-approval is required for certain doctor or specialist visits, ensure you get the authorisation number before your appointment.

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.

You will be stabilised at the closest hospital and transported to the nearest hospital on your network hospital list. This will not apply if you have selected Any hospital provider.

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. If you need to be hospitalised for some conditions, we will allocate a case manager to follow up regarding your hospital stay.

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

If a 3-month general waiting period is applied, you must wait 3 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 must 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 Prescribed Minimum Benefits cover the condition. A list of the Prescribed Minimum Benefits is available on www.medicalschemes.com.

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 healthcare expenses from your 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 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.

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

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 aid and medical insurance are both designed to help cover healthcare costs, but they work in different ways and offer different levels of protection.

Medical aid is provided by a registered medical scheme and offers comprehensive healthcare cover. Members pay a monthly contribution and receive benefits for a wide range of healthcare services, including hospitalisation, doctor consultations, specialist care, chronic medication, and preventive healthcare, depending on their chosen plan. South African medical schemes are regulated by the Medical Schemes Act and must cover Prescribed Minimum Benefits (PMBs) when the scheme's rules are met.

Medical insurance is an insurance product that provides limited cover for specific medical events or healthcare needs, such as day-to-day doctor visits, hospital cash payouts, accident cover, or gap cover. Benefits are defined in the policy, and medical insurance does not provide the same level of comprehensive healthcare cover as medical aid. It is regulated under insurance legislation rather than the Medical Schemes Act.

Key differences between medical aid and medical insurance:

If you're looking for broad, long-term healthcare protection and access to private healthcare, medical aid is generally the more comprehensive option. If you only need limited cover for certain medical expenses or want to supplement existing healthcare cover, medical insurance may be a more affordable alternative.

Medical aid will not disappear entirely, but its role will undergo significant changes. Once the NHI is fully implemented, medical schemes will no longer be allowed to cover any healthcare services that the NHI provides. For all services included in the NHI’s benefit package, you will have to use the NHI system.

Medical aids will still be allowed to operate, but only by offering complementary cover. This means medical aid will cover services that the NHI does not include. So while medical aid won’t fall away, it will become more limited and focused on non-NHI services.

Read our press release regarding the NHI Bill.

You need to be over the age of 18 to apply for medical aid on your own. Your monthly income will help determine which medical aid option you can afford and qualify for. Your currently health status, including any pre-existing conditions will determine which medical aid plan will suit you best.

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

Some medical scheme options have a medical savings account. This is a percentage of your monthly contribution, up to a maximum of 25% and 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 must pay for your day-to-day medical expenses out of your pocket. On the Extender Option, 25% of your contribution is available in a savings account to cover day-to-day expenses. Suppose this component is not enough to cover your annual day-to-day expenses. In that case, 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 based on your family size).

It is important to note that your Savings do not pay for chronic and hospitalisation benefits. Funds in the savings account that are not utilised are carried over to the following year. If you resign from the Scheme and still have funds in your savings account, this will be paid out to you.

Download the Momentum App so that you can:

• View your digital membership card.
• View your benefit information.
• View your claims history and get your claims statements.
• Pre-notify for certain Health Platform Benefits and get pre-authorisation for hospital admissions.
• Register on the maternity programme.
• Check your balances for HealthSaver⁺, Personal Medical Savings Account, HealthReturns⁺, and Active Dayz^TM.
• Book a health or fitness assessment.
• Request travel certificates, and more.

⁺ 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.