Introduction
The Incentive 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.
10% of your contribution goes to a dedicated Personal Medical Savings Account (Savings) to cover your day-to-day expenses. If you need more day-to-day cover, 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 Custom 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 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. Under the hospitalisation benefit, hospital accounts and related costs incurred in hospital (from admission to discharge) are covered – provided that 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 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 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: Standard formulary, or
Associated GPs and Courier pharmacy: Entry level formulary, or State: State formulary |
| Chronic conditions covered | Cover for 32 conditions: 26 conditions, according to the Chronic Disease List in the Prescribed Minimum Benefits: no annual limit applies
6 additional conditions: limited to R13 100 per family per year |
The Chronic Benefit covers certain life-threatening conditions that need ongoing treatment. You may choose Any, Associated or State as your Chronic Benefit provider. There is no overall 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 6 conditions (refer to brochure for a list of these 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 provider |
| Savings | Fixed at 10% of total contribution |
10% of your contribution goes to a dedicated Personal Medical Savings Account to cover your day-to-day expenses, such as GP visits and prescribed medicine. If you need more day-to-day cover, you can choose to make use of Momentum HealthSaver.
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 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 Major Medical Benefits: 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. Momentum Medical 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/treatments if performed in a day hospital OR the Specialised Procedures/Treatments 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 Savings |
| 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 | R400 000 per beneficiary per year, thereafter a 20% co-payment applies. Momentum Medical Scheme reference pricing applies to chemotherapy and adjuvant medication
If you choose State as your chronic provider, you need to obtain your oncology treatment from ICON providers 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 Savings or HealthSaver, if available. |
| Dentistry related to trauma | The hospital account is paid at the negotiated rate. The anaesthetist, 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 Savings or HealthSaver, if available |
| Other in-hospital procedure | |
| Maternity confinements | 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 co-payment of R2 900 per scan and pre-authorisation |
| Medical and surgical appliances in-hospital (such as support stockings, knee and back braces, etc) | R8 400 per family |
| Prosthesis – internal (including knee and hip replacements, permanent pacemakers, etc) | Cochlear implants: R214 200 per beneficiary, maximum 1 event per year
Intraocular lenses: R8 540 per beneficiary per event, maximum 2 events per year Other internal prostheses: R64 000 per beneficiary per event, maximum 2 events per year |
| Prosthesis – external (such as artificial arms or legs, etc) | R29 400 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 | R67 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 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 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 | 32 conditions | |
| Limit | 26 conditions, according to Chronic Disease List in Prescribed Minimum Benefits – no annual limit applies.
6 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 Benefits: Benefits are subject to available Savings; claims are paid at cost with no sub-limits | |
| Provider | Any
|
| Acupuncture, Homeopathy, Naturopathy, Herbology, Audiology, Occupational and Speech therapy, Chiropractors, Dieticians, Biokinetics, Orthoptists, Osteopathy, Audiometry, Chiropody, Physiotherapy and Podiatry | Subject to Savings, if available |
| Mental health (incl. psychiatry and psychology) | Subject to Savings, if available |
| Dentistry – basic (such as extractions or fillings) | Subject to Savings, if available |
| Dentistry – specialised | 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 Other specialised dentistry: Subject to Savings, if available |
| External medical and surgical appliances (incl. hearing aids, glucometers, blood pressure monitors, wheelchairs etc) | Subject to Savings, if available |
| General practitioners | Subject to Savings, if available |
| Specialists | Subject to Savings, if available |
| Optical and optometry (incl. contact lenses and refractive eye surgery | Subject to Savings, if available |
| Pathology (such as blood sugar or cholesterol tests) | Subject to Savings, if available |
| Radiology (such as X-rays) | Subject to Savings, if available |
| MRI and CT scans, magnetic resonance cholangiopancreatography (MRCP), whole body radioisotope and PET scans | Covered from Major Medical Benefit, subject to R2 900 co-payment per scan and pre-authorisation |
| Prescribed medication | Subject to Savings, if available |
| Over-the-counter medication | Subject to Savings, if available |
* 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 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 (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 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 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 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 consultations | ||
| Nurse home visits | 3 visits: Day after return from hospital, and 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.