Introduction
The Evolve Option provides cover for hospitalisation at the Evolve Network of private hospitals. There is no overall annual limit for hospitalisation. There is a standard Evolve Option co-payment for all Major Medical Benefits including non-emergency Prescribed Minimum Benefits, except in the case of motor vehicle accidents, maternity confinements or emergency treatment.
You need to use State facilities for all your chronic treatment, including doctors, scripts and medication.
You have cover for two virtual GP consultations from the GP Virtual Consultation Network, which includes Hello Doctor+. The Health Platform provides cover for a range of day-to-day benefits, such as preventative screening tests, certain check-ups and more. If you need cover for more day-to-day expenses, like additional GP visits or prescribed medicine, you can make use of Momentum HealthSaver+. HealthSaver is a complementary product offered by Momentum that lets you save for medical expenses not covered on your option.
Momentum Medical Scheme’s 2025 benefit and contribution amendments have been submitted to the Council for Medical Schemes and are subject to approval by the Regulator.
This focus page summarises the 2025 benefits available on the Evolve Option. Scheme Rules always take precedence and are available on request.
Major Medical Benefit
| Provider | Evolve Network hospitals. Certain procedures are only covered in day hospitals (here is the List of procedures covered in any day facility on the Evolve Option ) |
| Limit | No overall annual limit applies |
| Rate | Associated specialists are covered in full. Other specialists covered up to 100% of the Momentum Medical Scheme Rate. Hospital accounts are covered in full at the rate agreed upon with the hospital group |
| Specialised procedures/treatment | Certain procedures/treatments covered, refer to Focus on specialised procedures/treatment |
| Co-payments | R1 920 per authorisation including non-emergency Prescribed Minimum Benefits, except for motor vehicle accidents, maternity confinements and emergency treatment and when you involuntarily use a non-Designated Service Provider. An additional co-payment may apply for certain specialised procedures/treatment, refer to Focus on co-payment |
This benefit includes cover for hospitalisation and certain specialised procedures/treatment. There is no overall annual limit on hospitalisation. Claims are paid up to 100% of the Momentum Medical Scheme Rate. Under the hospitalisation benefit, hospital accounts and related costs incurred in hospital (from admission to discharge) are covered – provided that treatment has been authorised. Specialised procedures/treatment do not necessarily require admission to hospital and are included in the Major Medical Benefit – provided that the treatment is clinically appropriate and has been authorised.
A co-payment of R1 920 per authorisation applies to Major Medical Benefits including for non-emergency Prescribed Minimum Benefits, except for motor vehicle accidents, maternity confinements, emergency treatment and when you involuntarily use a non-designated Service Provider. An additional co-payment may apply for certain specialised procedures.
If pre-authorisation is not obtained, a 30% co-payment will apply on all accounts related to the event and the Scheme would be responsible for 70% of the negotiated tariff, provided authorisation would have been granted according to the Rules of the Scheme. In the case of an emergency, you or someone in your family or a friend must obtain authorisation within 72 hours of admission. Some procedures are only covered in day hospitals, such as cataract surgery and some sinus procedures – here is the List of procedures covered in any day facility on the Evolve Option only.
Chronic Benefit
| Chronic provider and formulary | State facilities and State formulary |
| Chronic conditions covered | 26 conditions covered according to the Chronic Disease List in the Prescribed Minimum Benefits |
The Chronic Benefit covers certain life-threatening conditions that need ongoing treatment. On the Evolve Option, chronic benefits are available from State facilities only. Chronic cover is provided for 26 conditions according to the Chronic Disease List, which forms part of the Prescribed Minimum Benefits. Chronic benefits are subject to registration and approval by the Scheme.
Day-to-day Benefit
| Day-to-day provider | Any provider |
| Day-to-day benefit |
2 virtual consultations from the GP Virtual Consultation Network, which includes Hello Doctor. 2 physiotherapist or biokineticist consultations per beneficiary for sports injuries, up to R1 120 per year. You can add HealthSaver to provide cover for your day-to-day healthcare expenses, such as additional GP visits and prescribed medicine |
You have cover for two virtual consultations from the GP Virtual Consultation Network, which includes Hello Doctor. If you need cover for other day-to-day expenses, like GP visits or prescribed medicine, you can choose to make use of Momentum HealthSaver. HealthSaver is a complementary product offered by Momentum that lets you save for medical expenses not covered by your option.
Health Platform Benefit
| Provider | Any provider |
Health Platform Benefits are paid by the Scheme up to a maximum rand amount per benefit, provided you notify us before using certain benefits. This unique benefit encourages health awareness, enhances the quality of life and gives peace of mind through:
- preventative care and early detection;
- maternity programme; and
- health education and advice.
Contributions
Maximum of 3 children charged for
Benefit Schedule
Major Medical Benefit
| Major Medical Benefit | |
| General rule applicable to the Major Medical Benefit: You need to contact us for pre-authorisation before making use of your Major Medical Benefits. For some conditions, like cancer, you will need to register on a health management programme. The Scheme will pay benefits in line with the Scheme Rules and the clinical protocols that the Scheme has established for the treatment of each condition. The sub-limits specified below apply per year. Should you not join in January, your sub-limits will be adjusted pro-rata (this means it will be adjusted in line with the number of months left in the year). | |
| Provider | Evolve Network hospitals. Certain procedures are only covered in day hospitals. See a list of these procedures here. The list of day hospitals is available on the Momentum App. You can download the app from the Play Store, App Store or AppGallery |
| Overall annual limit | None |
| Co-payments | R1 920 per authorisation including non-emergency Prescribed Minimum Benefits, except for motor vehicle accidents, maternity confinements and emergency treatment An additional co-payment may apply for specialised procedures, as indicated below. |
| Co-payments for specialised procedures/treatment | |
| The standard Evolve Option co-payment of R1 920 per authorisation applies to these procedures and treatment regardless of where they are performed. Plus the specialised procedures/treatment co-payment of R3 840 per authorisation applies if performed in an acute or day hospital | |
| Arthroscopies, Back and neck surgery*, Carpal tunnel release, Functional nasal and sinus procedures, Joint replacements*, Laparoscopies | Performed in a day hospital or acute hospital, subject to the relevant co-payment listed above |
| Gastroscopies, Colonoscopies, Cystoscopies, Sigmoidoscopies, Nail surgery, Removing of extensive skin lesions | Performed out of hospital, in a day hospital or in an acute hospital, subject to the relevant co-payment listed above |
| Conservative back and neck treatment*, Removal of minor skin lesions, Treatment of diseases of the conjunctiva, Treatment of headache, Treatment of adult influenza, Treatment of adult respiratory tract infections | Low severity cases are not covered by the Scheme but can be paid from Momentum HealthSaver, if available
High severity cases in an acute hospital are paid by the Scheme, subject to the relevant co-payment listed above |
| * Covered at State facilities | |
| Hospitalisation | |
| Benefit | Associated specialists are covered in full. Other specialists are covered up to 100% of the Momentum Medical Scheme Rate. Hospital accounts are covered in full at the rate agreed upon with the hospital group |
| High and intensive care | No annual limit applies |
| Casualty or after-hour visits | Subject to Momentum HealthSaver, if available |
| Renal dialysis | Limited to Prescribed Minimum Benefits at State facilities |
| Oncology | R200 000 per beneficiary per year, thereafter a 20% co-payment applies. Momentum Medical Scheme Reference Pricing applies to chemotherapy and adjuvant medication. You need to get your oncology treatment and medication from the Evolve Network of Oncologists |
| Organ transplants | Limited to Prescribed Minimum Benefits at State facilities |
| In-hospital dental and oral benefits | Not covered. Maxillo-facial trauma covered at State facilities, limited to Prescribed Minimum Benefits |
| Maternity confinements | No annual limit applies |
| Neonatal intensive care | No annual limit applies |
| Medical and surgical appliances in hospital (such as support stockings, knee and back braces, etc.) | R7 530 per family |
| Prosthesis – internal (incl. permanent pacemakers, cochlear implants, etc). Joint replacements, including knee and hip surgery, are limited to Prescribed Minimum Benefits at State facilities | Intraocular lenses: R6 300 per beneficiary per event,
maximum 2 events per year Other internal prosthesis: R42 000 per beneficiary per event, maximum 2 events per year |
| Prosthesis – external (such as artificial arms or legs) | R27 000 per family |
| MRI and CT scans, magnetic resonance cholangiopancreatography (MRCP), whole body radioisotope and PET scans | No annual limit applies, subject to co-payment of R3 200 per scan |
Mental health
|
Limited to Prescribed Minimum Benefits at Evolve Network hospitals |
| Take-home medicine | 7 days’ supply |
| Trauma benefit | Covers certain day-to-day benefits that form part of the recovery following specific traumatic events, such as near drowning, poisoning, severe allergic reaction and external and internal head injuries. Appropriate treatment related to the event is covered as per authorisation |
| Medical rehabilitation, private nursing, Hospice and step-down facilities | R58 000 per family |
| Health management programmes for conditions such as mental health, HIV/Aids and oncology | Your doctor needs to register you on the appropriate health management programme |
| Immune deficiency related to HIV
Anti-retroviral treatment HIV related hospital admissions |
No annual limit applies at preferred provider R48 300 per family at Evolve Network hospitals |
| Emergency medical transport in South Africa by
Netcare 911 |
No annual limit applies |
| International emergency medical transport by preferred provider | R5 000 000 per beneficiary per 90-day journey. This benefit includes R15 500 for emergency optometry, R15 500 for emergency dentistry and R765 000 terrorism cover. A R2 180 co-payment applies per emergency out-patient claim |
| Specialised procedures/treatment | |
| Certain specialised procedures/treatment covered (when clinically appropriate) in - and out of hospital | |
Chronic Benefit
|
Chronic Benefit | |
|
General rule applicable to the Chronic Benefit: Benefits are subject to registration on the Chronic Management Programme and approval by the Scheme | |
|
Provider |
State facilities |
|
Cover |
26 conditions covered, according to Chronic Disease List in the Prescribed Minimum Benefits |
Day-to-day Benefit
| Day-to-day Benefit | |
| General rule applicable to the Day-to-day Benefit: Benefits are subject to Momentum HealthSaver, if available (see Momentum Complementary Product brochure for more details on HealthSaver) | |
| Acupuncture, Homeopathy, Naturopathy, Herbology, Audiology, Occupational and Speech therapy, Chiropractors, Dieticians, Biokinetics, Orthoptists, Osteopathy, Audiometry, Chiropody, Physiotherapy and Podiatry | Subject to HealthSaver if available |
| Mental health (incl. psychiatry and psychology) | Subject to HealthSaver if available |
| Dentistry – basic (such as extractions or fillings) | Subject to HealthSaver if available |
| Dentistry – specialised | Subject to HealthSaver if available |
| External medical and surgical appliances (incl. hearing aids, glucometers, blood pressure monitors, wheelchairs etc) | Subject to HealthSaver if available |
| General practitioners | 2 virtual consultations from the GP Virtual Consultation Network, which includes Hello Doctor. Consultations include scripting of medication where required. Medication will be subject to Momentum HealthSaver, if available |
| Sports injury benefit | 2 physiotherapist or biokineticist visits per beneficiary per year for treatment related to sports injuries. Covered at 100% of the Momentum Medical Scheme Rate, up to a maximum of R1 120 per beneficiary per year. You need to get pre-authorisation |
| Specialists | Subject to HealthSaver if available |
| Optical and optometry (incl. contact lenses and refractive eye surgery | Subject to HealthSaver if available |
| Pathology (such as blood sugar or cholesterol tests) | Subject to HealthSaver if available |
| Radiology (such as X-rays) | Subject to HealthSaver if available |
| MRI and CT scans, magnetic resonance cholangiopancreatography (MRCP), whole body radioisotope and PET scans | Covered from Major Medical Benefit, subject to R3 200 co-payment per scan and pre-authorisation |
| Prescribed medication | Subject to HealthSaver if available |
| Over-the-counter medication | Subject to HealthSaver if available |
Health Platform Benefit
|
Health Platform Benefit | ||
|
General rule applicable to the Health Platform Benefit: Health Platform benefits are paid by the Scheme up to a maximum Rand amount per benefit. You do not need to pre-notify before using Health Platform Benefits, except for dental consultations, pap smears, general physical examinations and HIV tests. Where pre-notification is required, you can pre-notify quickly and easily on the Momentum App, via the web chat facility or by logging on to momentummedicalscheme.co.za. You may also send us a WhatsApp or call us on 0860 11 78 59. | ||
|
What is the benefit? |
Who is eligible? |
How often? |
|
Preventative care | ||
|
Baby immunisations |
Children up to age 6 |
As required by the Department of Health |
|
Flu vaccines |
Children between 6 months and 5 years Beneficiaries 60 and older All high-risk beneficiaries |
Once a year |
|
Tetanus diphtheria injection |
All beneficiaries |
As needed |
|
Pneumococcal vaccine |
Beneficiaries 60 and older High-risk beneficiaries |
Once a year |
|
Early detection tests | ||
|
Dental consultation (incl. sterile tray and gloves) |
All beneficiaries |
Once a year |
|
Pap smear consultation (nurse, GP or gynaecologist) |
Women 15 and older |
Based on type of pap smear (see below) |
|
Pap smear (pathologist) Standard or LBC (Liquid based cytology) Or HPV PCR screening test (If result indicates high risk, then a follow-up LBC is also covered) |
Women 15 and older Women 21 to 65 |
Once a year Once every 3 years
|
|
Mammogram |
Women 38 and older |
Once every 2 years |
|
DEXA bone density scan (radiologist, GP or specialist) |
Beneficiaries 50 and older |
Once every 3 years |
|
General physical examination (GP consultation) |
Beneficiaries 21 to 29 |
Once every 5 years |
|
Beneficiaries 30 to 59 |
Once every 3 years | |
|
Beneficiaries 60 to 69 |
Once every 2 years | |
|
Beneficiaries 70 and older |
Once a year | |
|
Prostate specific antigen (pathologist) |
Men 40 to 49 |
Once every 5 years |
|
Men 50 to 59 |
Once every 3 years | |
|
Men 60 to 69 |
Once every 2 years | |
|
Men 70 and older |
Once a year | |
|
Health assessment: Blood pressure test, cholesterol and blood sugar tests (finger prick tests), height, weight and waist circumference measurements |
All principal members and adult beneficiaries |
Once a year |
|
Cholesterol test (pathologist): Only covered if health assessment results indicate total cholesterol of 6 mmol/L and above |
Principal members and adult beneficiaries |
Once a year | |
|
Blood sugar (glucose) test (pathologist): Only covered if health assessment results indicate blood sugar levels of 11 mmol/L and above |
Principal members and adult beneficiaries |
Once a year | |
|
Glaucoma test |
Beneficiaries 40 to 49 |
Once every 2 years | |
|
Beneficiaries 50 and older |
Once a year | ||
|
HIV test (pathologist) |
Beneficiaries 15 and older |
Once every 5 years | |
|
Maternity programme (subject to registration on the Maternity programme between 8 and 20 weeks of pregnancy) | |||
|
Doula benefit |
Women registered on the programme |
2 visits per pregnancy | |
|
Antenatal visits (Midwives, GP or gynaecologist) |
12 visits | ||
|
Nurse home visits |
2 visits, the day after returning from hospital following childbirth and 2 weeks later | ||
|
Urine tests (dipstick) |
Included in antenatal visits | ||
| Pathology tests |
Blood group, creatinine, full blood count, glucose strip, haemoglobin estimation and Rhesus factor |
1 test | |
|
Urinalysis |
12 tests | ||
| Urine tests (microscopic exams, antibiotic susceptibility and culture) | As indicated | ||
| Scans | 2 pregnancy scans. We cover 3D and 4D growth scans up to the rate that we pay for 2D scans | ||
|
Paediatrician visits |
Babies up to 12 months registered on the programme |
2 visits in baby’s first year | |
|
Health line | |||
|
24-hour emergency health advice |
All beneficiaries |
As needed | |