Focus on the medical rehabilitation benefit

Physical rehabilitation 

Certain illnesses, injuries, accidents or surgical procedures can leave you with physical challenges or disabilities. Physical rehabilitation is a therapeutic programme designed to assist you in regaining your strength or movement as well as restoring your independence after such an event. This treatment can take place at home with help from a family member or caregiver or at a step-down facility. The nature of the rehabilitation will determine where it needs to take place.  

Physical rehabilitation also equips you to make daily living easier going forward, especially if these disabilities are permanent. Treatments and services that may be covered under the medical rehabilitation benefit include: 

• Step-down facilities
• Occupational therapy
• Speech therapy
• Physiotherapy
• Wound care
• Stoma care
• Home nursing
• Social workers 

What are the available benefits? 

The type of benefits required for rehabilitation will be determined by the nature of the injury, illness, procedure or disability.

What is a disability?

A disability is any condition that impairs one’s everyday activities. Disabilities may be physical, cognitive, mental, sensory, emotional, developmental, or a combination of these. Disabilities may be present at birth, develop over your lifetime, or occur after a traumatic event. A disability may be visible or hidden, permanent or temporary and may have minimal or substantial impact on a person’s abilities.  

Examples of physical disabilities include recovery from a hip replacement or a heart bypass, while sensory disabilities affect sight, hearing, smell, touch and taste. A cognitive disability affects brain function, such as memory loss after a head injury or a stroke. Intellectual disabilities are characterised by below-average intelligence, while mental health issues, such as severe depression or schizophrenia are considered mental disabilities. 

What is physical rehabilitation?

We usually don’t think about the great gift we have to move, bend, lift, throw or push without limitation. But an injury or illness can take away these abilities and suddenly everyday activities become extraordinary tasks.

Physical rehabilitation is the process of restoring and regaining physical strength and function via an integrated team of specialists, including doctors, nurses, psychologists, physiotherapists, social workers, speech therapists and occupational therapists. 

Who is eligible?

Members who have suffered a life-altering event or injury who are usually hospitalised for treatment, are eligible. A discharge plan from your treating doctor is required. This discharge plan will be specific to your condition and usually includes details of your follow-up visits and investigations, medication and medical devices/appliances, a medical rehabilitation plan and transfer to a step-down facility or Hospice, where appropriate.

The rehabilitation plan may include a home evaluation to ensure that your home environment is safe and suitable for your needs during the rehabilitation process. A Momentum Medical Scheme case manager will monitor your progress, working closely with your treating medical team.

Medical schemes cannot provide unlimited funding for rehabilitation. Depending on your injuries, it is possible that you may not regain 100% of function that you previously enjoyed. Every case differs and, while we do not want to refuse our members benefits, funding cannot be continued indefinitely. Cover will end when you reach the point of no further functional benefit, or if there is evidence of progress that includes the transfer of skills to a caregiver or family member. Please note that frail care is a Scheme exclusion and will not form part of this benefit. 

How to register for treatment in a step down facility

1. We need a letter of motivation from your treating doctor, including a detailed clinical report which outlines:

• The diagnosis and ICD-10 code;
• The current clinical condition;
• The estimated length of stay if transferring from another facility;
• The completed assessment from a facility with a valid practice number; and  
• The treatment plan, length of stay requested, including treatment with tariff codes to be charged for all practices, such as physiotherapists, social worker, etc. 

2. Your treating doctor or hospital case manager can send the letter of motivation to us via email at [email protected]. The discharge plan will be assessed by one of our case managers according to clinically appropriate protocols and evidence-based medicine. 

 3. We will send a response to your treating doctor or hospital case manager within 48 hours.

4. If you need to appeal a decision, you can send an email to us at [email protected]. We will review the appeal and provide feedback. 

How to register for home nursing or Hospice

1. We need a letter of motivation from your treating doctor, including a detailed clinical report which outlines:

• The diagnosis and ICD-10 code;
• The current clinical condition;
• The estimated length of time the service is required for;
• The completed assessment from a facility with a valid practice number; and 
• The treatment plan/services that will be provided, including the tariff codes to be charged. 

2. Your treating doctor or nursing agency can send the above information to us via email at [email protected]. The request will be assessed by one of our case managers according to clinically appropriate protocols and evidence-based medicine.

3. We will send a response to your treating doctor or nursing agency within 48 hours.

4. If you need to appeal a decision, you can send an email to us at [email protected]. We will review the appeal and provide feedback. 

How to register for wound care

1. We need a letter of motivation from your treating doctor, including a detailed clinical report from the nursing sister who will perform the wound care, which outlines:

• The diagnosis and ICD-10 code; 
• Dated, colour photographs of the wound; 
• The estimated dates for wound care; 
• The valid practice number; 
• The tariff codes to be charged for wound care; and 
• The details of any all items/dressings. 

2. Your treating doctor or nursing sister can send the letter of motivation to us via email at [email protected]. The request will be assessed by one of our case managers according to clinically appropriate protocols and evidence-based medicine.

3. We will send a response to your treating doctor or nursing sister within 48 hours.

4. If you need to appeal a decision, you can send an email to us at [email protected]. We will review the appeal and provide feedback.

Updated progress reports from the treating providers will need to be provided weekly to the Scheme, so we are able to monitor the progress of the rehabilitation for benefit alignment.