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 we get confirmation that you or your dependants have committed fraud.
If I resign from the Scheme, when can I claim?
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 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 on 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 your membership of the new medical scheme starts.
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 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 your HealthSaver+ funds.
If pre-approval is required for certain doctor or specialist visits, ensure you get the authorisation number before your appointment.
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 not on my network hospital list?
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.
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. If you need to be hospitalised for some conditions, we will allocate a case manager to follow up regarding your hospital stay.
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 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.
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 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.
Will the Scheme still pay for chronic medication and hospitalisation when I am in the self-funding gap?
Yes, the Scheme will still cover chronic medication and hospitalisation.
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.
How do I select the option that’s best for me?
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.
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% 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.
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 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™.
- Calculate your HealthReturns+.
- Book a health or fitness assessment.
- Download your health tax and travel certificates.