Introduction
The Summit Option includes cover for hospitalisation at any private hospital. There is no overall annual limit for hospitalisation. Extensive day-to-day and chronic benefits are available from any provider. 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. The Health Platform Benefit provides cover for a range of benefits such as preventative screening tests, certain check-ups and more.
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 Summit Option. Scheme Rules always take precedence and are available on request.
Major Medical Benefit
| Provider | Any hospital |
| Limit | No overall annual limit applies |
| Benefit | Associated specialists covered in full
Other specialists covered up to 300% 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) |
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 300% 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 treatment has been pre- 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. 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.
Chronic Benefit
| Chronic provider and Formulary | Any provider
Comprehensive formulary applies |
| 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: accumulate to overall day-to-day limit of R33 000 per beneficiary. This is a combined limit incorporating both day-to-day cover and cover for the 36 additional conditions |
The Chronic Benefit covers certain life-threatening conditions that need ongoing treatment. You have the freedom of choice to get your chronic prescription and medication from any provider, subject to a comprehensive formulary. If you choose to get your medication from outside the formulary, a co-payment of the cost difference between the selected item and the formulary price is payable. 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. An additional 36 conditions are covered subject to the overall day-to-day limit of R33 000 per beneficiary (this is a combined limit incorporating both day-to-day cover and cover for the 36 additional chronic 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 |
| Day-to-day benefit | Covered from risk benefit, subject to overall day-to-day limit of R33 000 per beneficiary and sub-limits. This is a combined limit incorporating both day-to-day cover and cover for the 36 additional conditions |
This benefit provides for day-to-day medical expenses, such as GP visits and prescribed medicine, and is paid from the risk benefit. The benefits are subject to an overall day-to-day limit of R33 000 per beneficiary and certain sub-limits apply. (The overall day-to-day limit of R33 000 is a combined limit incorporating both day-to-day cover and cover for the 36 additional chronic conditions).
Health Platform Benefit
| Provider | Any |
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 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 hospital |
| Overall annual limit | None |
| Hospitalisation | |
| Benefit | Associated specialists covered in full.
Other specialists covered up to 300% 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 |
| Oncology | No annual limit applies. Momentum Medical Scheme Reference Pricing will apply to chemotherapy and adjuvant medication. Specialised oncology benefits are available for certain biologicals and immunologicals, subject to criteria |
| 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 and the anaesthetist account is covered up to 300% 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, dentist, dental specialist and maxillo-facial surgeon accounts are covered up to 300% of the Momentum Medical Scheme Rate |
| Extraction of impacted wisdom teeth | The hospital account is paid at the negotiated rate and the anaesthetist account is covered up to 300% of the Momentum Medical Scheme Rate. 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 co-payment of R2 900per scan and pre-authorisation |
| Medical and surgical appliances in-hospital (such as support stockings, knee and back braces, etc) | R8 830 per family, subject to pre-authorisation |
| 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) | R23 600 per family |
Mental health
|
R48 400 per beneficiary |
| Take-home medicine | Medicine for 7 days |
| 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 any provider
R92 600 per family at any hospital |
| Emergency medical transport in South Africa by Netcare 911 | No annual limit applies |
| International emergency medical transport by preferred provider | R9 010 000 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) | |
Chronic Benefit
| Chronic Benefit | ||
| General rule applicable to Chronic Benefits: Benefits are subject to registration on the Chronic Management Programme and approval by the Scheme. | ||
| Provider | You can use any provider of your choice | |
| Cover | Cover for 62 conditions: 26 conditions according to Chronic Disease List in Prescribed Minimum Benefits - no annual limit applies
Cover for 36 additional conditions, subject to overall day-to-day limit of R33 000 per beneficiary. (This is a combined limit incorporating both day-to-day cover and cover for the 36 additional conditions) | |
Day-to-day Benefit
| Day-to-day Benefit | |
| General rule applicable to the Day-to-day Benefit: Benefits are paid at 100% of the Momentum Medical Scheme Rate, subject to the annual sub-limits specified below and an overall day-to-day limit of R31 300 per beneficiary. This is a combined limit incorporating both day-to-day cover and cover for 36 additional chronic conditions. The sub-limits specified apply per year unless stated otherwise. 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 | You can use any provider of your choice |
| Acupuncture, Homeopathy, Naturopathy, Herbology, Audiology, Occupational and Speech therapy, Chiropractors, Dieticians, Biokinetics, Orthoptists, Osteopathy, Audiometry, Chiropody, Physiotherapy and Podiatry | R9 420 per family. Subject to overall day-to-day limit of R33 000 per beneficiary |
| Mental health (incl. psychiatry and psychology) | R28 300 per family. Subject to overall annual day-to-day limit of R33 000 per beneficiary |
| Dentistry – basic (such as extractions or fillings) | Subject to overall annual day-to-day limit of R33 000 per beneficiary |
| Dentistry – specialised (such as bridges or crowns) | R19 800 per beneficiary, R47 700 per family. Subject to overall annual day-to-day limit of R33 000 per beneficiary. 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 pre-authorisation |
| External medical and surgical appliances (incl. hearing aids, glucometers, blood pressure monitors, wheelchairs etc) | R38 400 per family. R22 200 sub-limit for hearing aids. Subject to overall annual day-to-day limit of R33 000 per beneficiary |
| General practitioners | Subject to overall annual day-to-day limit of R33 000 per beneficiary |
| Specialists | Subject to overall annual day-to-day limit of R33 000 per beneficiary |
| Optical and optometry (incl. contact lenses and refractive eye surgery | Overall limit of R5 800 per beneficiary. Frame sub-limit of R2 950 Subject to overall annual day-to-day limit of R33 000 per beneficiary |
| Pathology (such as cholesterol tests) | Subject to overall annual day-to-day limit of R33 000 per beneficiary |
| Radiology (such as X-rays) | Subject to overall annual day-to-day limit of R33 000 per beneficiary |
| MRI and CT scans, magnetic resonance cholangiopancreatography (MRCP), whole body radioisotope and PET scans | Covered from Major Medical Benefit, subject to a R2 900 co-payment per scan and pre-authorisation |
| Prescribed medication | R25 700 per beneficiary, R42 300 per family. Subject to overall annual day-to-day limit of R33 000 per beneficiary |
| Over-the-counter medication (including prescribed vitamins and homeopathic medicine) | Not covered |
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 (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 | |
| Pediatrician 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 | |