Introduction
The Extender Option includes cover for hospitalisation in private hospitals. There is no overall annual limit for hospitalisation. You can choose to have access to any hospital, or you can choose to save on your monthly contribution by selecting to use a specific list of private hospitals (referred to as Associated hospitals).
For chronic treatment, you can choose to have access to any doctor for your chronic scripts and any pharmacy for your chronic medication. Or you can choose to save on your monthly contribution by selecting to use a list of Associated doctors for your chronic script and Medipost courier pharmacy for your chronic medication. Alternatively, you can choose to use State facilities for your chronic script and chronic medication to obtain the maximum contribution saving.
The Health Platform Benefit provides cover for a range of benefits such as preventative screening tests, certain check-ups and more.
25% of your contribution is available in a Personal Medical Savings (Savings) account to cover day-to-day expenses. If this Savings 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). Once you have reached this Threshold amount, your claims will be paid by the Scheme from the Extended Cover benefit.
You can choose to make use of Momentum HealthSaver+ for additional day-to-day expenses and to pay for out-of-pocket expenses before your Extended Cover is activated. 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 Extender Option. Scheme Rules always take precedence and are available on request.
Major Medical Benefit
| Provider | Any or Associated hospitals |
| Limit | No overall annual limit applies |
| Benefit | Associated specialists covered in full
Other specialists covered up to 200% 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/treatment covered (refer to the Member brochure for a list of procedures and treatment covered) |
| Co-payments | Co-payments may apply for specialised procedures/treatment (see co-payment table below) |
This benefit includes cover for hospitalisation and certain specialised procedures/treatment. There is no overall annual limit on hospitalisation. Associated specialists are covered in full, while other specialists are covered up to 200% of the Momentum Medical Scheme Rate. Hospital accounts are covered in full at the rate agreed upon with the hospital group. Hospital accounts and related costs incurred in hospital (from admission to discharge) are covered – provided treatment has been pre-authorised.
Specialised procedures/treatment do not necessarily require admission to hospital and are included in the Major Medical Benefit – provided the treatment is clinically appropriate and has been pre-authorised. If 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 may obtain authorisation within 72 hours of admittance. If you choose Associated hospitals and you do not use this provider, a 30% co-payment will apply on the hospital account.
Chronic Benefit
| Chronic provider and Formulary | Any provider: Extended formulary, or
Associated GPs and Courier pharmacy: Entry level formulary, or State: State formulary |
| Chronic conditions covered | Cover for 62 conditions:
26 conditions, according to the Chronic Disease List in Prescribed Minimum Benefits: no annual limit applies 36 additional conditions: limited to R13 200 per family per year |
The Chronic Benefit covers certain life-threatening conditions that need ongoing treatment. On the Extender Option, you may choose Any, Associated or State as your Chronic Benefit provider. There is no annual limit for chronic cover for the 26 conditions according to the Chronic Disease List, which forms part of the Prescribed Minimum Benefits. A limit of R13 100 per family per year applies to an additional 36 conditions. Chronic benefits are subject to registration on the Chronic Management Programme and approval by the Scheme.
Day-to-day Benefit
| Day-to-day provider | Any or Associated (Members who have chosen Associated as their chronic provider must use an Associated GP for GP consultations) |
| Savings | Fixed at 25% of total contribution |
| Threshold | R33 400 for the principal member
R29 000 per adult dependant R9 600 per child (applies up to a maximum of three children) |
This benefit provides for day-to-day medical expenses, such as GP visits and prescribed medicine. 25% of your contribution is available to cover day-to-day expenses. This is known as Personal Medical Savings. If this component is not enough to cover your annual day-to-day expenses, you will have a self-funding gap to pay out of your own pocket, up to the Threshold (a pre-determined amount based on your family size). Once you reach the Threshold, your claims will be paid by the Scheme from Extended Cover.
If you select Any or State as your chronic provider, you may visit any GP for your GP consultations. If you select Associated as your chronic provider, you must use an Associated GP for your GP visits. If not, claims will only accumulate at 70% of the Momentum Medical Scheme Rate to Threshold, and a 30% co-payment will apply once in Extended Cover.
Health Platform Benefit
| Provider | Any or Associated 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
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 | Any or Associated hospitals |
| Overall annual limit | None |
| Co-payments for specialised procedures/treatment | |
| A co-payment of R1 920 per authorisation applies to these procedures/treatment if performed in a day hospital OR the Specialised Procedures/Treatment co-payment of R3 840 per authorisation if performed in an acute hospital (hospital where overnight admissions apply) | |
| 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 Day-to-day Benefits or Momentum HealthSaver, if available
High severity cases in an acute hospital are paid by the Scheme, subject to the relevant co-payment listed above |
| Hospitalisation | |
| Benefit | Associated specialists covered in full. Other specialists covered up to 200% 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 Day-to-day Benefit |
| Renal dialysis | No annual limit applies. If you choose State as your chronic provider, you need to make use of State facilities for your renal dialysis |
| Oncology | Limited to R500 000 per beneficiary per year, thereafter a 20% copayment applies. Momentum Medical Scheme reference pricing applies to chemotherapy and adjuvant medication. Specialised oncology benefits are available for certain biologicals and immunologicals, subject to criteria.
If you choose State as your chronic provider, you need to obtain your oncology treatment from an ICON provider as authorised by the Scheme. If you choose State or Associated as your chronic provider, you need to obtain your oncology medication from Medipost |
| Organ transplants (recipient) | No annual limit applies |
| Organ transplants (donor): Only covered when the recipient is a member of the Scheme | R27 500 cadaver costs
R56 000 live donor costs (including transportation) |
| In-hospital dental and oral benefits | |
| Maxillo-facial surgery (excluding implants) and general anaesthesia for children under 7 | The hospital account is paid at the negotiated rate, subject to a R1 750 co-payment per authorisation. The anaesthetist account is covered up to 200% of the Momentum Medical Scheme Rate. The dentist, dental specialist and maxillo-facial surgeon accounts are paid from available day-to-day benefits, subject to the day-to-day limits |
| Dentistry related to trauma | The hospital account is paid at the negotiated rate. The anaesthetist account and the dentist, dental specialist and maxillo-facial surgeon accounts are covered up to 200% of the Momentum Medical Scheme Rate |
| Extraction of impacted wisdom teeth | The hospital account is paid at the negotiated rate, subject to a R3 450 co-payment for day hospitals and a R6 500 co-payment for other hospitals per authorisation. The anaesthetist account is covered up to 200% of the Momentum Medical Scheme Rate and the dentist, dental specialist and maxillo-facial surgeon accounts are paid up to 100% of the Momentum Medical Scheme Rate |
| Implants and all other in-hospital dental treatment | The cost of implants, as well as the hospital, anaesthetist, dentist, dental specialist and maxillo-facial surgeon accounts are paid from available day-to-day benefits, subject to the day-to-day limits |
| Other in-hospital procedure | |
| Maternity confinement | No annual limit applies |
| Neonatal intensive care | No annual limit applies |
| MRI and CT scans, magnetic resonance cholangiopancreatography (MRCP), whole body radioisotope and PET scans (in- and out of hospital) | No annual limit applies, subject to R2 900 co-payment per scan and pre-authorisation |
| Medical and surgical appliances in-hospital (such as support stockings, knee and back braces, etc) | R8 830 per family |
| Prosthesis – internal (including knee and hip replacements, permanent pacemakers, etc) | Cochlear implants: R234 000 per beneficiary, maximum 1 event per year
Intraocular lenses: R9 130 per beneficiary per event, maximum 2 events per year. Other internal prostheses: R88 200 per beneficiary per event, maximum 2 events per year |
| Prosthesis – external (such as artificial arms or legs) | R30 600 per family |
Mental health
|
R48 400 per beneficiary |
| 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 | R72 000 per family |
| Health management programmes for conditions such as chronic renal disease, organ transplants, mental health, HIV/Aids and oncology | Your doctor needs to register you on the appropriate health management programme |
Immune deficiency related to HIV
|
No annual limit applies at preferred provider
R92 600 per family at your chosen hospital provider |
| Emergency medical transport in South Africa by Netcare 911 | No annual limit applies |
| International emergency medical transport by preferred provider | R8 220 000 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 070 co-payment applies per emergency out-patient claim |
| Specialised procedures or treatment | |
| Certain specialised procedures/treatment covered (when clinically appropriate) in- and out-of-hospital (refer to the Member brochure for a list of procedures and treatment covered) | |
* If you choose the Associated chronic provider, a 30% co-payment will apply if you do not use an Associated GP for the GP consultations covered under the Health Platform.
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 | Any, Associated or State* |
| Cover | 62 conditions |
| Limit | 26 conditions covered according to Chronic Disease List in Prescribed Minimum Benefits – no annual limit applies.
36 additional conditions - Limited to R13 100 per family per year |
| *If the State cannot provide you with the chronic medicine you need, you may obtain your medicine from Ingwe Primary Care Network providers, subject to a Network formulary and Scheme approval | |
* If you choose the Associated chronic provider, a 30% co-payment will apply if you do not use an Associated GP for the GP consultations covered under the Health Platform.
Day-to-day Benefit
| Day-to-day Benefit | |
| General rule applicable to the Day-to-day Benefit: 25% of your contribution is available to cover day-to-day expenses. This is known as Savings. If this component is not enough to cover your annual day-to-day expenses, you will have a self-funding gap to pay out of your own pocket, up to the Threshold determined by your family size. Once you have reached this Threshold, your claims will be paid by the Scheme from Extended Cover. Claims add up to the Threshold and are paid from Extended Cover at the Momentum Medical Scheme Rate, subject to the sub-limits specified below. The sub-limits apply before and after the Threshold is reached.
The annual Threshold levels are:
| |
| Provider | Any or Associated (Members who have chosen Associated as their chronic provider must use an Associated GP for GP consultations) |
| Acupuncture, Homeopathy, Naturopathy, Herbology, Audiology, Occupational and Speech therapy, Chiropractors, Dieticians, Biokinetics, Orthoptists, Osteopathy, Audiometry, Chiropody, Physiotherapy and Podiatry | Unlimited within the provisions of the General Rule mentioned above |
| Mental health (incl. psychiatry and psychology) | R25 200 per family |
| Dentistry – basic (such as extractions or fillings) | Unlimited within the provisions of the General Rule mentioned above |
| Dentistry – specialised (such as bridges or crowns) | R17 300 per beneficiary, R44 900 per family.
Both in-and out of hospital dental specialist accounts accumulate towards the limit Dental specialist accounts for extraction of impacted wisdom teeth in doctors’ rooms: Covered from Major Medical Benefit at 100% of the Momentum Medical Scheme Rate, subject to R1 750 co-payment and pre-authorisation |
| External medical and surgical appliances (incl. hearing aids, glucometers, blood pressure monitors, wheelchairs etc) | R31 300 per family
R9 420 sub-limit per family for hearing aids Subject to pre-authorisation |
| General practitioners | Depending on the chronic provider selected:
Any or State provider: 100% of the Momentum Medical Scheme Rate Associated provider: 100% of the Momentum Medical Scheme Rate for Associated GPs Non-Associated provider: 70% of the Momentum Medical Scheme Rate for non-Associated GPs |
| Specialists | 100% of the Momentum Medical Scheme Rate |
| Optical and optometry (incl. contact lenses and refractive eye surgery | Overall limit of R5 300 per beneficiary
Frame sub-limit of R2 890 |
| Pathology (such as blood sugar or cholesterol tests) | Unlimited within the provisions of the General Rule mentioned above |
| Radiology (such as X-rays) | Unlimited within the provisions of the General Rule mentioned above |
| MRI and CT scans, magnetic resonance cholangiopancreatography (MRCP), whole body radioisotope and PET scans | Covered from Major Medical Benefit, R2 900 co-payment applies per scan |
| Prescribed medication | R22 200 per beneficiary, R42 100 per family |
| Over-the-counter medication (incl. prescribed vitamins and homeopathic medicine) | Subject to Savings, does not accumulate to Threshold |
* If you choose the Associated chronic provider, a 30% co-payment will apply if you do not use an Associated GP for the GP consultations covered under the Health Platform.
Health Platform Benefit
| Health Platform Benefit |
| General rule applicable to the Health Platform Benefits: 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
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 (including 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 a 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 | ||
| Online antenatal and postnatal classes | 18-month subscription | ||
| Online video consultations with lactation specialist | Initial and follow-up consultations | ||
| Nurse home visits | 3 visits: Day after return from hospital following childbirth, then after 2 and 6 weeks | ||
| Urine tests (dipstick) | Included in antenatal visits | ||
| Pathology tests | Antiglobin, blood group, creatinine, full blood count, platelet count, Rhesus factor and Rubella antibody | 1 test | |
| Glucose strip and haemoglobin estimation | 2 tests | ||
| Urinalysis | 12 tests | ||
| Urine tests (microscopic exams, antibiotic susceptibility and culture) | As indicated | ||
| Scans | Women registered on the programme | 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 | |
* If you choose the Associated chronic provider, a 30% co-payment will apply if you do not use an Associated GP for the GP consultations covered under the Health Platform.
Disclaimer: +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.