The Major Medical Benefit includes cover for hospitalisation, as well as certain specialised procedures/ treatment and specialised scans.
Overview of the cover provided in hospital across the six options
| Option | Cover | Limit | Provider |
| Ingwe Option | Up to 100% of the Momentum Medical Scheme Rate | No overall annual limit applies | Any hospital, Ingwe Network hospitals or State hospitals |
| Evolve Option | Up to 100% of the Momentum Medical Scheme Rate | No overall annual limit applies | Evolve Network hospitals Certain procedures are only covered in day hospitals |
| Custom Option | Up to 100% of the Momentum Medical Scheme Rate | No overall annual limit applies | Any or Associated hospitals |
| Incentive Option | Up to 200% of the Momentum Medical Scheme Rate | No overall annual limit applies | Any or Associated hospitals |
| Extender Option | Up to 200% of the Momentum Medical Scheme Rate | No overall annual limit applies | Any or Associated hospitals |
| Summit Option | Up to 300% of the Momentum Medical Scheme Rate | No overall annual limit applies | Any hospital |
1 On the Custom and Evolve Options, a co-payment of R1 830 is payable per authorisation, except for motor vehicle accidents, maternity confinements and emergency treatment. This co-payment applies even in the case of Prescribed Minimum Benefits, excluding emergencies. A co-payment may also apply per authorisation for certain specialised procedures and treatments mentioned below.
2 On the Incentive and Extender Options, co-payments may apply for certain specialised procedures or treatments.
Specialised procedures and treatment co-payments
| How specialised procedures and treatment are covered on the Evolve Option | |
| The standard Evolve Option co-payment of R1 830 per authorisation applies to these procedures and treatments regardless of where they are performed Plus the specialised procedures co-payment of R3 660 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 |
| Gastroscopes, 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 HealthSaver+, if available
High severity cases in an acute hospital are paid by the Scheme, subject to the relevant co-payment listed above |
View the list of day hospitals on the Momentum app or momentummedicalscheme.co.za.
+ HealthSaver is an complementary product offered by Momentum.
* Covered at State facilities
| How specialised procedures and treatment are covered on the Custom Option | |
| The standard Custom Option co-payment of R1 830 per authorisation applies to these procedures and treatments regardless of where they are performed Plus the specialised procedures co-payment of R1 830 per authorisation applies if performed in a day hospital, or 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 |
| Gastroscopes, 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 HealthSaver+, if available
High severity cases in an acute hospital are paid by the Scheme, subject to the relevant co-payment listed above |
View the list of day hospitals on the Momentum app or momentummedicalscheme.co.za.
+ HealthSaver is an complementary product offered by Momentum.
| How specialised procedures and treatment are covered on the Incentive and Extender Options | |
| A co-payment of R1 830 per authorisation applies to these procedures and treatments if performed in a day hospital
Or a co-payment of R3 660 per authorisation applies to these procedures and treatments 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 |
| Gastroscopes, 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 HealthSaver+, if available
High severity cases in an acute hospital are paid by the Scheme, subject to the relevant co-payment listed above |
View the list of day hospitals here or on the Momentum app.
+ HealthSaver is an complementary product offered by Momentum.
Hospitalisation and Major Medical Benefit
This benefit covers hospital accounts and related costs incurred in hospital from admission to discharge in line with the Scheme Rules and the clinical protocols that Momentum Medical Scheme has established for the treatment of each condition.
- The hospitalisation benefit includes seven days’ supply of take-home medication on discharge from hospital.
- Cover for MRI and CT scans, magnetic resonance cholangiopancreatography (MRCP), whole body radioisotope and PET scans in- and out-of-hospital:
- Ingwe: Limited to Prescribed Minimum Benefits at State facilities.
- Custom and Evolve: No annual limit applies, subject to co-payment of R3 050 per scan.
- Incentive, Extender and Summit Options: No annual limit applies, subject to co-payment of R2 770 per scan.
- Dental benefits for impacted wisdom teeth, dentistry related to trauma and general anaesthesia for children under 7 years:
- Ingwe and Evolve Options: No cover. Maxillo-facial trauma is covered at State facilities, limited to Prescribed Minimum Benefits.
- Custom, Incentive, Extender and Summit Options: View the 2024 Focus on dental benefit, which includes details of the cover for maxillo-facial surgery (excluding implants), general anaesthesia for children under 7, dentistry related to trauma as well as extraction of impacted wisdom teeth in and out of hospital.
Obtaining authorisation for Major Medical Benefits
You need to obtain pre-authorisation for hospitalisation, day clinic admissions, specialised procedures/ treatment, specialised scans (MRI, CT, magnetic resonance cholangiopancreatography (MRCP), whole body radioisotope and PET scans) and any other Major Medical Benefits. You need to obtain a separate pre-authorisation from Momentum Medical Scheme for any in-hospital physiotherapy. We provide pre-authorisation once we have verified benefits and applied Scheme Rules and protocols.
If the hospital or doctor obtains the authorisation on your behalf, we will send you a confirmation via email if we have your email address in our records. It is important for you to check if you will need to pay any co-payments or shortfalls as a result of not using a Designated Service Provider, or as a result of any benefit limits or protocols.
How to obtain pre-authorisation
- Log in to the Momentum App or contact our member call centre:
- via our web chat facility on momentummedicalscheme.co.za;
- send us a WhatsApp message on 0860 11 78 59;
- email us at [email protected] (please include your membership number in your email)
- visit momentummedicalscheme.co.za, click on "Contact us" and then on “Click here to join a virtual help session” for one of our consultants to assist you; or
- call us on 0860 11 78 59.
- Make a note of the authorisation number.
- Give the authorisation number to your provider.
When you contact us, make sure you have the following information available:
- Your membership number
- The name and details of the patient
- The reason for hospital admission, procedure or specialised scan
- The procedure code (CPT), diagnosis code (ICD-10) and tariff code (these details are available from your treating doctor)
- The date of admission
- The contact details and practice number of the referring GP
- The contact details and practice number of the specialist
- The name and practice number of the hospital, day clinic or radiologist.
Important notes
- You need to obtain pre-authorisation from Momentum Medical Scheme at least 48 hours before you or your dependants are admitted to a hospital, receive treatment covered under the Specialised Procedures/Treatment benefit or Major Medical Benefit, or have a specialised scan.
- If you do not get authorisation in time, you will need to pay a 30% co-payment on all accounts related to the claim event and the Scheme would be responsible for 70% of the negotiated tariff, provided authorisation would have been granted according to the Rules and protocols of the Scheme, except in the case of medical emergencies. This is in addition to any other co-payments that apply.
- In the case of an emergency, you, a family member or a friend must obtain authorisation within 72 hours of admittance.
- Ingwe Option: If you choose Ingwe Network hospitals and do not use this provider, you will have a co-payment of 30% on the hospital account. If you choose State hospitals and do not use this provider, you will have a co-payment. This co-payment will be the difference in the cost between State facility charges and the amount charged by the provider you use.
- Evolve Option: If you do not use Evolve Network hospitals, you will have a 30% co-payment on the hospital account.
- Custom, Incentive and Extender Options: If you choose Associated hospitals and do not use this provider, you will be liable for a 30% co-payment on the hospital account.