Emerald Value Option Benefit Guide - Your 2018 - Working towards a healthier you - GEMS
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Your 2018
Emerald Value Option
Benefit Guide
Passionate about your health
Working towards a healthier you
This guide shows you what benefits you have access to on the Emerald
Value option. Keep this guide handy for quick access to your benefit 4 Emergency consultation: In emergency cases where you cannot get
information. to your nominated GP, you are allowed to visit a non-nominated GP.
Access to this benefit is not automatic. You need to contact GEMS
The Emerald Value option offers the same rich benefits as the existing by calling the call centre on 0860 00 4367 or by sending an email
Emerald option, but at a more affordable rate. to enquiries@gems.gov.za to ensure that you do not incur a 30%
co-payment for such a visit.
Important information to remember about the Emerald Value option:
The Emerald Value option forms part of the (REO) Network which is made 5 Emergency visits will be processed retrospectively via the current
emergency exception management process similar to PMBs.
up of General Practitioners (GP), dental providers, specialists, renal dialysis
A co-payment will be overridden for all emergency consultation claims.
providers, document-based care providers and pharmacies who have
agreed to charge the contracted rate and follow GEMS Network and
managed care rules. The Emerald Value option has a Hospital Network
as well.
6 Use a hospital that is on the Emerald Value Hospital Network for
your in-hospital needs. View the Emerald Value Hospital Network
on www.gems.gov.za.
1 You must nominate a General Practitioner (GP) on the GEMS Network
for you and your beneficiaries. Your nominated GP is the healthcare 7 Always get a referral from your nominated GP before you consult
provider you will consult for all your doctor visits. This will help prevent a specialist to avoid paying out-of-pocket. Remember to ask for a
waste of funds by ensuring duplicate diagnostic tests are not done; specialist on the GEMS Specialist Network if you need to consult a
reduce medicine errors; enhance access to services, and reduce paediatrician, psychiatrist, obstetrician, gynaecologist or a physician
hospital admissions and re-admissions. In turn, you will receive the best (which also includes pulmonologists, gastroenterologists, neurologists,
possible healthcare from the right healthcare provider, with the right cardiologists and rheumatologists). Network GPs and specialists have
skills, at the right time and have better control over how your benefits agreed to charge contracted rates so that you will not have to pay
are managed. any out-of-pocket expenses for your consultations. Your day-to-day
benefits will also last longer if you use healthcare providers that are on
the GEMS network.
2 You may nominate a secondary GP; we encourage you to use your
primary nominated GP.
8 Remember to call 0860 00 4367 to get pre-authorisation for all hospital
visits, out-patient visits to a hospital, MRI scans, CT scans or radio-
3 If you consult a non-nominated GP, you will have to pay 30% out of isotope studies, in-hospital physiotherapy, ambulance transportation
your pocket. and specialised dentistry.
Your health and wellness
With GEMS Fitness, you can expect support to:
Electronic Health Record (EHR)
• make healthier lifestyle choices
A record of your complete medical history, in one secure
• increase your physical activity
location. Sign in to Member Online to give your healthcare
• eat healthier foods
provider access to your medical history. This ensures that you
• improve your sleeping habits
receive the best treatment for your condition.
• reduce your stress level
• quit smoking
• manage your weight whether you want to lose or gain
GEMS Fitness • keep your heart healthy and reduce the risk of a heart attack
• stay motivated, and lots more
An exercise and health programme suited to your needs as a
valued GEMS member. GEMS Fitness facilitates a stimulating To benefit from the GEMS Workplace Fitness Programme, your department
and supportive environment to help you improve your health needs to get on board and agree to the terms and conditions of the
and enhance the quality of your life. programme.
You can access GEMS Fitness via GEMS Member Online on You don’t have to do it alone. We are all in this together!
www.gems.gov.za.
Your health and wellness cont.
Join GEMS Fitness in a few easy steps Benefits of joining
1. You need to be a principal GEMS member or a dependant employed Group exercise sessions at work.
by government.
Access to on-site fitness tests, desk exercises, telephonic and
2. Your department needs to agree and sign the terms and conditions
on-site access to health coaches and dietitians.
(T&Cs) of the programme.
3. Once the department signs T&Cs and is on board, GEMS will come to
your department and host an activation event. This is the first step to Health tips via SMSs, brochures and emails.
becoming part of an experience like no other.
Access to the GEMS Fitness Portal to record and track your
4. You need to attend an activation event and complete a form to activate activity and health progress.
your GEMS Workplace Fitness membership.
Start your journey to better health today. Check the GEMS website > Member online > Fitness Journey, to see which departments have joined. You can also call
us on 0860 00 4367 where we will explain the process or email enquiries@gems.gov.za with the subject line “GEMS Fitness Programme” for more information.
Self-help tools
GEMS DotMobi
Quick and easy access to your benefit information, 24/7 Open your internet browser on your
WAP-enabled cell phone and type in m.gems.
SMS Benefit Check Service gov.za to view your claims, available benefits
and other benefits. Select ‘Member Online’ and
Check your benefits by sending an SMS to 33489 with the keyword log in using your membership number and PIN.
‘Benefit’, your membership number, the benefit category and the
dependant code (you find this on the back of your membership card).
For example: Benefit, 0001414, GP, 01 (each SMS will cost you R1.50).
Find a GEMS Network provider
Member Online
Visit www.gems.gov.za, click on the ‘Find a Network
Visit www.gems.gov.za, click on the ‘Sign in’ tab at the top of the page
Provider’ banner on the homepage. Once on the
and log in. If you are not registered to Member Online, you will need your
GEMS Network page, click ‘Find a Network Provider’
member number, identity number and a unique password to register.
on the left-hand menu. Now simply fill in the fields
provided. Alternatively, you can contact the GEMS
Call Centre on 0860 00 4367 or send an email to
enquiries@gems.gov.za.
Glossary
Understand this frequently used medical scheme terminology to know your benefits better.
A ACDL: DTP:
Additional Chronic Disease List. A list of chronic diseases the Scheme Diagnosis and Treatment Pairs are a list of the 270 PMB conditions in
covers in addition to the CDL conditions. the Medical Schemes Act linked to the broad treatment definition. A
list of these is available on www.gems.gov.za under the Member tab
B Benefit option: on the Prescribed Minimum Benefits page.
Each of the six GEMS benefit options – Sapphire, Beryl, Ruby,
Emerald Value, Emerald and Onyx – has a different range of G GP:
healthcare benefits. General Practitioner. A doctor based in the community who treats
patients with minor or chronic illnesses and refers those with serious
Benefit schedule: conditions to a hospital.
A listing of the benefits provided for by each benefit option.
I ICD-10 code:
C CDL: ICD-10 code stands for International Classification of Diseases and
Chronic Disease List. A list of the 26 specific chronic diseases Related Health Problems (10th revision). It is a coding system that
schemes need to provide a minimum level of cover for, as stated by translates the written description of medical and health information
law. into standard codes. These codes are used by the Scheme and
healthcare providers to identify your condition.
CT and MRI scans:
Specialised and more advanced type of X-rays. M MEL:
DMP: Medicine Exclusion List. A list of medicines that GEMS does not
D DMP: cover.
Disease Management Programme. Specific care programmes to help
members manage various chronic diseases and conditions. MPL:
Medicine Price List. A reference list we use to work out the prices of
DSP: groups of medicines.
Designated Service Provider. A healthcare provider the Scheme has
an agreement with to provide Prescribed Minimum Benefits (PMBs) to
members at specific prices.
Glossary cont. Stay informed
P PDF: Please keep us updated with your latest contact details to make
Professional Dispensing Fee. A maximum fee that a pharmacist or sure that we can keep you informed at all times.
dispensing doctor may charge for their services, as set out in South
African law. Check that we have your current information by sending an email to
enquiries@gems.gov.za or signing in and updating your details via
PMBs: Member Online at www.gems.gov.za
Prescribed Minimum Benefits. Basic benefits that all medical
schemes in South Africa must cover according to the law.
Pre-authorisation request (PAR):
The process of informing GEMS of a planned procedure before
the event so that we can assess your benefit entitlement.
Pre-authorisation must be obtained at least 48 hours before the
event. In emergency cases, authorisation must be obtained within
one working day after the event. Failing to get authorisation will
incur a co-payment of R1 000 per admission to hospital.
S Scheme rate:
The price agreed to by the Scheme for the payment of healthcare
services provided by healthcare providers to members of the
Scheme. 100% Scheme rate means the full amount GEMS has
agreed to pay for the service.
SEP:
Single Exit Price. The one price that a medicine manufacturer or
importer charges for medicine to all its pharmacies. This price is set
out in South African law.
T TTO:
Treatment Taken Out. The medicine you receive when you are
discharged from hospital. Usually lasts for 7 days.
Contact GEMS
Call: Email:
0860 00 4367 enquiries@gems.gov.za
Complaints:
complaints@gems.gov.za
Website: Compliments:
www.gems.gov.za compliments@gems.gov.za
Fax:
0861 00 4367
Postal address:
GEMS, Private Bag X782, Cape
Town, 8000
Or find us on
Facebook
The GEMS Member App is available for
free download from:
Disclaimer
This brochure contains a summary of medical benefits and contribution costs offered by GEMS for 2018. Should a dispute arise, the registered Rules of the Scheme will
apply. The registered Rules of the Scheme are available on the GEMS website at www.gems.gov.za, under About Us. You may also contact us directly to request a copy.
Working towards a healthier you
EMERALD VALUE – In-Hospital Benefits Prescribed minimum benefits (PMBs) – Unlimited, subject to PMB legislation • Service provided by DSP • PMBs override all benefit limitations Yearly hospital benefit (public hospitals, GEMS-approved private hospitals, registered unattached theatres, day clinics and psychiatric facilities) – Unlimited • GEMS hospital network • Includes accommodation in a general ward, high care ward and intensive care unit (ICU), theatre fees, medicines, materials and hospital equipment (including bone cement for prostheses) and neonatal care • Subject to use of network providers • A co-payment of R10 000 will apply if a non-network provider is used • Accommodation in private ward subject to motivation by attending practitioner • Co-payment of R1 000 per admission if pre-authorisation not obtained Alcohol and drug dependencies – Subject to pre-authorisation and managed care and use of network Allied health services – Includes chiropractors, dieticians, homeopaths, podiatrists, phytotherapist, social workers, registered counsellors, orthoptists, acupuncturists and Chinese medicine practitioners • Shared with out-of-hospital limit of R1 517 per family per year • Sub-limit of R759 per family for social workers and registered counsellors • Subject to GP and specialist referral rules • Subject to managed care protocols and services being related to admission diagnosis Alternatives to hospitalisation (sub-acute hospitals and private nursing) – Unlimited • Excludes frail care and recuperative holidays • Includes physical rehabilitation for approved conditions and home nursing – Hospice • Unlimited, subject to PMB legislation Blood transfusion – Unlimited, subject to PMB legislation • Includes cost of blood, blood equivalents, blood products and transport thereof • Includes erythropoietin Breast reduction – Unlimited Dental services (conservative, restorative and specialised) – Subject to list of approved services and use of day theatres within the network • Shared with out-of-hospital dental services • Limited to R4 918 per beneficiary per year • General anaesthesia and conscious sedation subject to managed care rules • Only applicable to beneficiaries with severe trauma, impacted third molars or under the age of 6 years • Lingual and labial frenectomies under general anaesthesia for children under the age of 8 subject to managed healthcare programme • Excludes osseo-integrated implants, all implant-related procedures and orthognathic surgery Emergency services (casualty department) – Subject to use of facility as per in-hospital benefits or other registered emergency facility • Paid from out-of-hospital GP services if pre-authorisation is not obtained GP services – Consultations and visits • Unlimited • Reimbursement according to Scheme-approved tariff file • General practitioner nomination rules apply Maternity (hospital, home birth and accredited birthing unit (public hospitals and designated private hospitals)) – Subject to use of network providers, registration on the Maternity Programme and managed care • Elective caesarian subject to second opinion Medical technologists – Unlimited • Subject to event pre-authorisation and case management Mental health – Accommodation, theatre fees, medicine, hospital equipment professional fees of GPs, Psychiatrists, Psychologists and Registered Counsellors • Limited to R17 639 per family per year • Limited to 1 individual psychologist consultation and 1 group psychologist consultation per day • Maximum of 3 days’ hospitalisation by GP • GP nomination rules apply • Educational and industrial psychologists excluded • All limits are subject to PMBs Oncology (chemo and radiotherapy) – In and out of hospital • Subject to use of network • Includes medicine and materials • Limited to R352 801 per family per year • Sub-limit of R240 004 per family per year for biological and similar specialised medicine • Includes cost of pathology, radiology, medical technologist and oncology medicine • Subject to MPL • Erythropoietin included in blood transfusion benefit • Excludes new chemotherapeutic medicines that have not demonstrated a survival advantage of more than 3 months in advanced and metastatic solid organ malignant tumours unless pre-authorised Organ and tissue transplants – Subject to clinical guidelines used in public facilities • Includes materials • Limited to R587 996 per beneficiary per year • Limit includes all costs associated with transplant including immuno-suppressants • Sub-limit of R19 960 per beneficiary per year for corneal grafts (imported corneal grafts subject to managed care rules) • Authorised erythropoietin included in blood transfusion benefit • Organ harvesting limited to South Africa, except for corneal tissue Pathology – Unlimited • Subject to pathology tests being related to admission diagnosis • Managed care rules apply Physiotherapy – Subject to use of network • Limited to R4 757 per beneficiary per year • Subject to PMBs – Post-hip, knee and shoulder replacement or revision surgery physiotherapy • 10 post-surgery physiotherapy visits (shared with out-of-hospital visits) up to a limit of R5 021 per beneficiary per event used within 60 days of surgery • GP referral required • Subject to pre-authorisation and managed care protocols and processes Prostheses – Covers prostheses and surgically implanted internal devices, including all temporary prostheses and all temporary or permanent devices used to assist with delivery of internal prostheses • Shared with medical and surgical appliances as well as out-of-hospital external prostheses limit of R40 010 per family per year • Scheme may obtain competitive quotes and arrange supply of prosthesis • Bone cement paid from in-hospital benefits • Shared sub-limit with out-of-hospital prosthetics and appliances of R4 394 for foot orthotics and prosthetics with a sub-limit of R1 255 for orthotic shoes, foot inserts and levelers per beneficiary per year • Foot orthotics and prosthetics subject to formulary • R500 for crutches per beneficiary per year • R5 500 for wheelchairs per beneficiary per year • R8 000 per hearing aid per beneficiary per year • Subject to internal and external devices being related to admission diagnosis and procedure • Subject to PMBs Radiology (advanced) – Shared with out-of-hospital advanced radiology limit of R21 166 per family per year • Specialist referral rules apply • Specific authorisation (in addition to hospital pre-authorisation) required for angiography, CT scans, MDCT, coronary angiography, MUGA scans, PET scans, MRI scans and radio-isotope studies Radiology (basic) – Unlimited • Specialist referral rules apply • Subject to use of network • Managed care rules apply Renal dialysis – Subject to clinical guidelines used in public facilities • In-hospital • Includes materials and related pathology tests • Includes cost of radiology, medical technologists, material and immuno suppressants • Limited to R251 993 per beneficiary per year for chronic dialysis • Acute dialysis included in the in-hospital benefit • Erythropoietin included in blood transfusion benefit • Pathology and radiology test subject to managed care Specialist services – Consultations and visits • Unlimited • Subject to GP referral and use of network provider • Reimbursement according to Scheme-approved tariff file • 100% of Scheme Rate for non-network providers • 130% of Scheme Rate for established network specialists Surgical procedures (including maxillo-facial surgery) – Unlimited • Subject to use of network or doctors’ rooms • Excludes osseo-integrated implants, all implant-related procedures and orthognathic surgery • Includes hospital procedures performed in practitioners’ rooms Key: Pre-authorisation is needed 100% of Scheme rate 100% of cost, subject to PMB legislation Subject to managed care rules Limited to PMBs
EMERALD VALUE – Out-of-Hospital Benefits
Personal Medical Savings Account (PMSA) – No PMSA
Allied health services – Includes chiropractors, dieticians, homeopaths, podiatrists, phytotherapists, social workers, registered counsellors, orthoptists, acupuncturists and Chinese medicine practitioners • Shared with in-hospital allied health services limit of R1 517 per family per year
• Sub-limit of R759 per family for social workers and registered counsellors • Subject to PMBs
Audiology, occupational therapy and speech therapy – Subject to day-to-day block benefit • Occupational or speech therapy performed in-hospital will be paid from the in-hospital benefit • Shared limit of R2 147 per beneficiary per year and R4 302 per family per year shared with
pathology and medical SAPPHIRE technology • Sub-limit – In-Hospitalof R1 726 per beneficiary Benefits and R3 450 per family per year • GP nomination and specialist referral rules apply
Block
SAPPHIRE benefit (day-to-day
– In-Hospital benefit) – Out Benefits
of hospital GP and specialist services,
familyphysiotherapy, maternity (where not covered under provided
maternitybybenefit DSP •programme), audiology, occupational
limitationstherapy, speech therapy, pathology and medical technology • Subject to use of network • Limited to
R4SAPPHIRE
400 per beneficiary – In-Hospital
Prescribed minimum
and R8 804 per family Benefits
benefits (PMBs) – R208 237
per year • Benefit is pro-rated from join date
per per annum, subject to PMB legislation • Service PMBs override all benefit
Circumcision
Prescribed Yearly
– Global hospital benefit –– (public hospitals, GEMS-approved private hospitals, registered withinunattached by theatres, dayof clinics and psychiatric tofacilities) – Includes accommodation in a general ward, high care ward and intensive care unit (ICU), theatre fees, medicines, materials
Prescribed minimumminimum benefits
fee
and hospital
of R1 421
benefits (PMBs)
(PMBs)
equipment
per beneficiary,
R208
R208 237
(including 237which
bone
per includes
per family
family
cement
per
per allannum,
relatedsubject
forannum,
prostheses)
costs
subject oftopost-procedure
PMB
PMB legislation
andtoneonatal legislation care
•• Service
care • Service Service month
provided
provided
provided
of procedure
byby DSP
DSP
DSP • PMBs• Out
• •Chronic
PMBs hospitalall
override
override
medicine
only
benefit
allprovided
benefit• Subject
limitations
limitations
by
pre-authorisation
chronic DSP • Subject to yearly hospital limit of R208 237 per family per year • TTO limited to 7 days • No limit per maternity confinement
Contraceptives
Yearly (oral, insertables, injectables and dermal) – Subject to formulary • Subject to acute medicine benefit limit • Sub-limit of R2 677 per beneficiary per year
Yearly hospital
hospital benefitbenefit
event, but (public
(publicsubject hospitals,
to yearlyGEMS-approved
hospitals, hospital limit and private
GEMS-approved private
registration hospitals,
hospitals,
on Scheme’s registered
registered Maternity unattached
unattached
Programme theatres,
theatres, day
• Co-paymentday clinics
clinics of R1and
and 000 psychiatric
psychiatric
per admission facilities)
facilities) –– Includes
Includes accommodation
if pre-authorisation not obtained in
accommodation in aa general
general ward, ward, high high care
care ward
ward andand intensive
intensive carecare unitunit (ICU),
(ICU), theatre
theatre fees, fees, medicines,
medicines, materials
materials
Dental
and services (conservative and restorative dentistry including acutecare medicine) – provided
Subject tobynetwork •• use • Shared with in-hospital dentistry sub-limit of R4 918 per beneficiary per year • Excludes osseo-integrated implants, all implant-related •• procedures and orthognathic surgery
and hospital
hospital equipment
equipment Alcohol
(including
(including
and
bone
bone
druglimit
cement
cement
dependencies
for
for prostheses)
prostheses) and
and neonatal
neonatal care •• Service
Service provided by DSP
DSP Chronic
Chronic medicine
medicine provided
provided by
by chronic
chronic DSP
DSP •• Subject
Subject to
to yearly
yearly hospital
hospital limit
limit of
of R208
R208 237
237 per
per family
family per
per year
year •• TTO
TTO limited
limited to
to 77 days
days No
No limit
limit per
per maternity
maternity confinement
confinement
•event,
Generalbut anaesthesia
subject to and conscious
yearly hospital sedation
and require –pre-authorisation
registration Subject
on to PMBs,
Scheme’s andpre-authorisation,
are subject
Maternity Programme to managedmanaged
• care
Co-paymentcarerulesprotocols
of(only
R1 000 andpertheadmission
applicable use of a DSP
to beneficiariesif with severe trauma,
pre-authorisation not impacted third molars or under the age of 6 years) • No pre-authorisation required for metal base dentures • Lingual and labial
obtained
event, but subject to yearly hospital limit and registration on Scheme’s Maternity Programme • Co-payment of R1 000 per admission if pre-authorisation not obtained
frenectomies underAllied general anaesthesia
health services for–children
Includes under the age ofdieticians,
chiropractors, 8 subject to managed healthcare
homeopaths, podiatrists, programme
phytotherapists, • 200%social of Schemeworkers, Rate for treatment
orthoptists, of bony impactions
acupuncturists and Chinese of third molars practitioners
medicine under conscious sedation
• Limited in doctors’
to PMBs roomsto•referral
• Subject Panoramic X-rays limited
by network GP andtoservices
one X-ray every
being three to
related years
admission diagnosis
Alcohol
Alcohol
per and
and drug
beneficiary drug dependencies
dependencies
• 4 bitewing X-rays per –– Subject
Subject
beneficiary to
to PMBs,
PMBs,
per year pre-authorisation,
pre-authorisation,
• Fluoride treatment managed
managed excluded care
care protocols
protocols
for and
and the
beneficiaries use
theolder
use than of
of aa DSP
DSPyears
16
Emergency
Allied healthassistance
Allied health services
services ––(road
Includes
Includes andchiropractors,
air) – Unlimited,
chiropractors, subjecthomeopaths,
dieticians,
dieticians, to PMB legislation
homeopaths, • Subject
podiatrists, to use of emergency
phytotherapists, social servicesorthoptists,
workers, DSP acupuncturists and Chinese medicine practitioners •• Limited to PMBs •• Subject to
to referral by
by network
network GP and
and services being related to to admission diagnosis
Alternatives to hospitalisation (sub-acute hospitalspodiatrists,and private phytotherapists,
nursing) – Subject social to workers, orthoptists,
yearly hospital limitacupuncturists
and sub-limit of andR20Chinese823 per medicine
family per practitioners
year • Excludes Limited frailtocare
PMBs Subjecthome
• Includes referral
nursing GP
– Hospice services
• 100% being of related
cost, subject admission
to PMBdiagnosis
legislation
General Practitioner (GP) services – Member nominated GPs • Subject to day-to-day block benefit and the use of nominated GPs • A 30% co-payment will apply to any out-of-hospital visit to a GP other than the nominated GP, irrespective of the doctor being on the network or not • Limited
to R4 400
Alternatives per to Blood
beneficiary transfusion
and R8 804 –
per family
Includes per costyear ofshared
blood, with
blood specialist
equivalents, services,blood physiotherapy
products and and maternity
transport •
thereof Covers consultations and approved minor procedures at member-nominated network providers • Limit is pro-rated • Reimbursement at 200% of Scheme Rate for procedures
Alternatives
specified to hospitalisation
by managed hospitalisation
care performed
(sub-acute
(sub-acute
in doctors’
hospitals
hospitals
rooms instead
and
and private
private
of in hospital
nursing)
nursing) –– Subject Subject to to yearly
yearly hospital
hospital limit limit and and sub-limit
sub-limit of of R20
R20 823 823 per per family
family perper year year •• Excludes
Excludes frail
frail care
care •• Includes
Includes home home nursing
nursing –– Hospice
Hospice •• 100% 100% of of cost,
cost, subject
subject to to PMB
PMB legislation
legislation
Blood transfusion Breast
– Includesreduction cost of–blood,
No benefit blood equivalents, blood products and transport thereof
GPBlood transfusion
network extender – Includes
benefitcost – For of beneficiaries
blood, blood equivalents, with chronic blood conditions products and transport
registered on disease thereof
management programme • 2 additional GP consultations at a network GP once block benefit is exhausted • The additional GP consultation at a nominated DSP/network provider is subject to
Breast Dental services care (conservative, restorative and specialised) – Only applicable to beneficiaries with severe trauma, impacted third molars or under the age of 6 years • Subject to yearly hospital limit and out-of-hospital dentistry limit • Excludes osseo-integrated implants, all implant
Breast reduction –– No
pre-authorisation and managed
reductionrelated No benefit
benefit
procedures, orthognathic
HIV infection, AIDS and related illness – Subject surgery to PMBsand andspecialised
managed care dentistry • Subject to
• Pre-exposure list of approved
prophylaxis included services
for highand riskuse of day theatres and DSP hospitals
beneficiaries
Dental
Dental services
services (conservative,
(conservative, restorative
restorative and
and specialised)
specialised) –– Only
Only applicable
applicable to to beneficiaries
beneficiaries with with severe
severe trauma,trauma, impacted
impacted third third molars
molars or or under
under the the age age of of 66 years
years •• Subject
Subject to to yearly
yearly hospital
hospital limit
limit andand out-of-hospital
out-of-hospital dentistry
dentistry limit
limit •• Excludes
Excludes osseo-integrated
osseo-integrated implants, implants, allall implant
implant
Infertility
related – Subject Emergency
to use of DSPservices (casualty department) –
related procedures,
procedures, orthognathic
orthognathic surgery surgery and and specialised
specialised dentistry dentistry •• Subject Subject to to list
list ofof approved
approved services services and and use use of of day
day theatres
theatres and and DSP DSP hospitals
hospitals
Maternity (ante- GP andservices
post-natal care) – 100%
– department)
Consultations of Scheme Rate paid from risk, if registered on Maternity Programme according• to Subject to: Maternity Programme tariff file forprotocols,
maternityManaged Careapplicable
Protocols and processes andand PMBs non-caesarianOR 100% of Scheme Rate paid from day-to-day block benefit,
ifEmergency
Emergency
not registered services
services (casualty
(casualtyProgramme
on the Maternity department) ––and visits
• Subject
• Subject
to PMBs
to yearly hospital limit • Reimbursement Scheme-approved
• (Kindly contact GEMS to obtain more detail on the consultations and benefits that may be funded under the GEMS Maternity Programme)
confinement, to both caesarian delivery
GP Maternity (hospital, home birth and accredited birthing unit (public hospitals and designated private hospitals)) – Subject to registration on the Maternity Programme • Elective caesarian
prostheses • In and out oftohospital
may be subject second•opinionShared•with Hospitalisation in designated private hospitals for
GP services
Medical
servicesand ––surgical
Consultations
Consultations appliances
post-discharge
and and••prostheses
visits
and complications
visits Subject
Subjectforto – Includes
yearly
tonewborns
yearly hospital
hospitalhearing
limited
limit
limit
toand
• Reimbursement
aids,
6• weeks
wheelchairs, mobility
Reimbursement• Includes
according
according
midwife
to
to Scheme-approved
scooters, oxygen cylinders,tariff
Scheme-approved
services • Co-payment tariff
of R1
file
nebulisers, for
file000for maternity
glucometers,
maternity
per admission
confinement,
colostomy applicable
confinement, kits, diabeticto
applicable
if pre-authorisation
both
toequipment,
not both caesarian
caesarian
obtained
and
and non-caesarian
foot orthotics and externaldelivery
non-caesarian delivery in-hospital internal prosthesis
limit of
Maternity R40 010
(hospital,per family
home per year
birth •
and Sub-limit of R15 611 for medical surgical appliances per family per year • Shared sub-limit with in-hospital prosthetics of R4 394 for foot orthotics and prosthetics with a sub-limit of R1 255 for orthotic shoes, foot inserts and levelers per beneficiary
Maternity
per year • Foot(hospital, Medical
orthotics home birth
andtechnologists
prostheticsand accredited
accredited
–limited
subject
birthing
birthing
to formulary
Includes
unit (public
•unit
R500 (public hospitals
hospitals
for crutches PMBsper
and designated
• and designated
beneficiary per year
private
private
•ofR5R1500
hospitals))
hospitals))
forper
–– Subject
wheelchairs Subject per
to registration
registrationperon
tobeneficiary onyear the
the •Maternity
Maternity
R8 000 per
Programme
Programme
hearing aid
•• Elective
Elective caesarian
caesarian
per beneficiary
may be
permay
subject to
yearbe• subject
second
Bilateraltohearing
secondaids opinion
opinion • Hospitalisation
every•36 Hospitalisation
months • Subject
in
in designated
designated private hospitals
to PMBs •private hospitals for
GP nomination for
and
post-discharge
post-discharge complications
complications for
for newborns
newborns limited to
to 66materials
weeks
weeks •••Includes
Limited
Includes
to
midwife
midwife
Subject
services
services •• to event
Co-payment
Co-payment
pre-authorisation
of R1 000
000 per admission
admission ifif pre-authorisation
pre-authorisation not
not obtained
obtained
specialist referral rules apply
Medical technologists Mental– health – materials
Accommodation, theatre fees,• medicine, hospitalpre-authorisation
equipment, professional fees of General Practitioners, Psychiatrists and Psychologists • Subject to pre-authorisation and managed care protocols • Educational and industrial psychologists excluded • Limited to PMBs
Mental
Medicalhealth (Consultations,
technologists – Includes
Includes materials •• Limited
assessments, treatment
Limited to
to PMBs
and/or
PMBs • Subject
counselling
Subject to
to event
eventby GP, Psychiatrist and Psychologist) – Consultations, assessments, treatments and/or counselling by GPs, psychiatrists and psychologists • If out-of-hospital treatment offered as alternative to hospitalisation,
pre-authorisation
then
Mental
Mental health
hospital
health –– Accommodation,
benefits will apply • Shared
theatre with fees,in-hospital
medicine, mental
hospitalhealth limit
equipment, of R17 639
professional per familyfees per year • Practitioners,
Sub-limit of R5Psychiatrists231 for out-of-hospital psychologist consultations • Limited toand 1 individual psychologist consultation and 1 andgroup psychologist consultation per day • Educational and
Accommodation,
Oncology (chemo theatreand are fees, medicine,
radiotherapy) hospital equipment,
– In and out of hospital • Includes professional fees of of General
Generaland
medicine Practitioners,
materials Psychiatrists
• Subject to and
and Psychologists
Psychologists
clinical guidelines•used
• Subject
Subject to
to pre-authorisation
in publicpre-authorisation
facilities and MPL and managed
managed
• Excludes
care
carenew protocols
protocols •• Educational and industrial
Educationalmedicines
chemotherapeutic industrial psychologists
psychologists
that have
excluded
excluded ••aLimited
not demonstrated Limited to PMBs
survivaltoadvantage
PMBs of more than
industrial psychologists excluded • All limits subject to PMBs
Optical services 3(eye months in advancedframes,
examinations, and metastatic lenses,solid contactorganlenses malignant tumours unless
(permanent pre-authorised
or disposable) and acute medicine) – All services included in benefit subject to optical managed care programme and network use • Sub-limit of R2 210 per beneficiary every second year and yearly
Oncology
Oncology (chemo
(chemo and
and and radiotherapy) –– In and out of hospital • Includes medicine and materials •• Subject to
to• clinical guidelines used in
in public facilities and MPL •• Excludes new chemotherapeutic medicines that have
have not demonstrated a survival
survival toadvantage of
of more than
limit of R4 417 perOrgan family •radiotherapy)
Framestissuelimited transplantstoInR1 and 289 –out • of hospital
Limited
Subject to 1•eye Includes
to pre-authorisation examination medicine
andper and guidelines
beneficiary
clinical materialsper benefitSubject
used inyear
public clinical
frameguidelines
1facilities and 1 pair used
• Subject ofto lenses
PMBs public
per facilities
beneficiary
• Includes and
everyMPL
materials secondExcludes
year • Nonew limitchemotherapeutic
will be applied to the medicines
number that of contact not
lensesdemonstrated
that may bearendered advantage
a beneficiary, more
asidethan
from
33 months
months in
in advanced
advanced and
and metastatic
metastatic solid
solid organorgan malignant
malignant tumours
tumours unless unless pre-authorised
pre-authorised
the indicated financial benefit limits • Benefit not pro-rated • Post-cataract surgery, optical PMB benefit limited to the cost of a bifocal lens not more than R1 061 for both lens and frame, with a sub-limit of R210 for the frame • Either spectacles or contact lenses will be funded in a benefit year,
Organbothand tissue Pathology – Subject to yearly forhospital
albinismlimit
not
Organ and tissue transplants
• Includes tinted
transplants lenses –– Subject
up to 35%
Subject totintpre-authorisation
to pre-authorisation and and
proven
and photophobia,
clinical
clinical guidelinessubject
guidelines used
used in to public
in pre-authorisation
public facilities
facilities •• Subject• Excludes
Subject to variable
to PMBs
PMBs tint and photochromic
•• Includes
Includes materials
materials lenses
Orthopedic
Pathology Disease Management
Physiotherapy – Programme
Post-hip, knee – Negotiated
and shoulder rate • Subject
replacement to managed
or revision care protocols
surgery and
physiotherapy processes • 10 post-surgery physiotherapy visits (shared with out-of-hospital visits) up to a limit of R5 021 per beneficiary per event used within 60 days of surgery
Pathology –– Subject
Subject to to yearly
yearly hospital
hospital limit limit
Pathology – Subject to day-to-day
Prostheses – block prostheses
Covers benefit • Limit and ofsurgically
R2 147 per beneficiary
implanted internalper devices,
year andincluding R4 302 per all family
temporary per year shared and
prostheses with all audiology,
accompanying occupational temporary therapy and speechdevices
or permanent therapy used • Includes
to assistliquid-based
withbeneficiary cytology pap
the guidance, smear and delivery of internal prostheses • Subject to the yearly hospital limit and
alignment
Physiotherapy
Physiotherapy ––– aGP Post-hip, knee and shoulder replacement or
or •revision surgery physiotherapy •• 10
10 post-surgery physiotherapy visits
visitsin(shared with out-of-hospital visits) up to
to aa394
limit of R5 021 per per event used within
withinofof60 days of surgery
Physiotherapy Post-hip,
nomination
sub-limit knee
of R23 andand 790 shoulder
specialist
per family replacement
referral perrules
year apply
• Bone revision
cementsurgery
Subject to managed
paid from physiotherapy
care and benefits
in-hospital network post-surgery
use
• Shared • Physiotherapyphysiotherapy
sub-limits performed
with out-of-hospital (shared
a network withhospital
prosthetics out-of-hospital
or instead
and visits) upR4
of hospitalisation
appliances of limitforwill
offoot
R5 021
paidper
beorthotics frombeneficiary
in-hospital
and per
prosthetics event
with•aused
benefit Sub-limit
sub-limit 60
R1days
R2 255of
147 forsurgery
per beneficiary
orthotic shoes, and foot
R4 287 per and
inserts family per per beneficiary
levelers
Prostheses
year shared –
with Covers
GP prostheses
services and – Post-hip,
surgically knee
implanted and shoulder
internal replacement
devices, including or revision
all temporary surgery physiotherapy
prostheses and all accompanying
• 10 post-surgery temporary
Prostheses – Covers prostheses and surgically implanted internal devices, including all temporary prostheses and all accompanying temporary or permanent devices used to assist with the guidance, alignment and delivery of internal prostheses • Subject
per year. Foot orthotics and prosthetics subject to formulary • R500 for crutches per beneficiary per year • R5 500 for wheelchairs or
physiotherapy permanent
per visits devices
(shared
beneficiary used
with
per yearto assist
in-hospital
• R4 with
visits)
500 the
perup guidance,
to a
hearing limitaidofalignment
R5
per 021 and
per
beneficiary delivery
beneficiary
per yearof internal
per
• event
Subject prostheses
used
to within
internal • 60Subject
and days
externalofto the
tosurgery yearly
devices
the hospital
yearlybeing limit
limittoand
related
hospital admission diagnosis
and
Prescribed
aa sub-limit
sub-limit of ofmedicine
R23
R23 and 790 and
per
790procedure injection
per family
family •per
per material
year
Subject
year ••toBone
PMBs
Bone – Prescribed
cement
cement paid paidand from
from in-hospital
administered
in-hospitalby benefits •• Shared
a professional
benefits Sharedlegallysub-limits
entitled
sub-limits with
with to out-of-hospital
do so • GP nomination
out-of-hospital prosthetics
prosthetics andand appliances
specialist
and appliances of
of R4
referral R4rules394
394 for
for foot
apply orthotics
• Subject
foot orthotics and
and prosthetics
to MPL and MEL – with
prosthetics Acute
with aa sub-limit
medical of
sub-limit R1
R1 255
255 for
conditions
of orthotic
• Subject
for orthotic to shoes, foot
foot inserts
formulary
shoes, • Limitand
inserts R3 levelers
and 528 perper
levelers beneficiary
beneficiary
per beneficiaryand
per
per year.
R10 583 per
year. Foot orthotics
Footfamily
orthotics and
and prosthetics
per year, subject to asubject
prosthetics sub-limit
subject to
to offormulary
R527 for••homeopathic
formulary R500
R500 for crutches
for servicesmedicine
crutches per
perper beneficiary
family perper
beneficiary year
year •• R5
annum
per 30%
R5 500
500 for
for wheelchairs
co-payment wheelchairs per
per beneficiary
on out-of-formulary per
per year
beneficiarymedicine year•••Includes
R4
R4 500 per
per hearing
500prescribed aid
aid per
hearingmaternity per beneficiary
vitamin supplement
beneficiary per
per year
year ••• Homeopathic
Subject
Subject to to internal and
and external
and alternative
internal external devices
medicine
devices being
being related
excluded unless to
related admission
prescribed
to admission bydiagnosis
a network
diagnosis
and Radiology (advanced) – Subject to list of approved
GPand–procedure
Chronic medical
procedure •• Subject to
to PMBs
Subjectconditions PMBs • CDL and DTP PMB chronic conditions • Subject to prior application and approval and use of chronic medicine pharmacy DSP • Limit of R10 583 per beneficiary and R21 310 per family per year • Unlimited for PMBs, subject to PMB legislation • 30%
co-payment Radiology
on out-of-formulary
Radiology (advanced) –– Subject (basic)
medicine
to list – Subject
and to yearly
voluntary hospital
use limit • •Includes
of non-DSP Once limit 2 x 2D ultrasound
is depleted, CDLscansbenefit per will be limited • Include benefit for life threatening allergies payable from risk and subject to managed care and formulary – Prescribed medicine from hospital stay (TTO)
pregnancy
•Radiology
Included in(advanced)
acute medicine Subject
benefittolimit list •of
ofTTO approved
approved services
limitedservicesto 7 days and must be related to admission diagnosis and procedure • Payable from risk once acute medication benefit limit is exhausted – Self-medicine (OTC) • Subject to formulary • Schedule 0, 1 and 2 medicines covered • Subject
Radiology (basic) Renal
–– Subjectdialysis – In hospital • Includes materials and related pathology tests • Subject to clinical guidelines used in public facilities
toRadiology (basic)benefit
acute medicine limit to
Subject to yearly
(event
yearly limithospital
of R237
hospital limit
limitper••beneficiary)
Includes
Includes 22 xxand 2D ultrasound
2Dsub-limit
ultrasound scans
of R889
scansper per pregnancy
pregnancyper year and a yearly family limit of R1 421 – Contraceptives • Subject to formulary • Subject to acute medicine benefit limit and sub-limit of R2 677 per beneficiary per year
perbeneficiary
Preventative Specialist services –
dialysiscare Inservices
hospital ••–Includes
Renal Consultations and visits • 100% of Scheme Rate for non-network providers •vaccination
130% of Scheme Ratevaccination
for established network specialists • Subject to yearly hospital limit • Reimbursement according to Scheme-approved
• Pneumococcaltariff file
Renal dialysis –– In hospital Payable materials
Includes from risk •and
materials and Includes
relatedInfluenza
related pathology
pathology vaccination,
tests
tests •• Subject HPV vaccination
Subject to
to clinical and Pneumococcal
clinical guidelines
guidelines used
used in in public
public facilities
facilities • Influenza and HPV vaccination (for female beneficiaries) limited to 1 per year unless indicated otherwise vaccination once every
5 years for beneficiaries Surgical at risk • Subject to(including
procedures managed maxillo-facial
care protocols and processes
surgery) – • Includes
Subject to screening
yearly hospital services
limit •provided
Subject by
to network
case pharmacies• Maxillo-facial surgery subject to yearly sub-limit of R20 823 per family • Excludes osseo-integrated implants, all implant-related procedures and orthognathic
management
Specialist services
Specialist services – Consultations
–– Consultations and visits
and visits • 100% of Scheme Rate for non-network providers • 130% of Scheme Rate for established network specialists • Subject to yearly hospital limit • Reimbursement according to Scheme-approved tariff file
Screening services surgery Serum cholesterol, bone •density 100%scan, of Scheme
pap smear Rate(including
for non-network liquid-based providers • 130%
cytology), of Scheme
prostate specificRate antigen,for established
glaucoma screening, network specialists
serum glucose, • Subjectocculttoblood
yearlytests,
hospital limit • Reimbursement
Thyrotropin (TSH) for neonatal according to Scheme-approved
hypothyroidism, mammogram and tariffother
file screening according to evidence-
Surgical
based
Surgical procedures
standard
procedurespractice(including
• Neonatalmaxillo-facial
(including hypothyroidismsurgery)
maxillo-facial screening––test
surgery) Subject
Subject– TSHto yearly
yearly hospital
to(Thyrotropin) hospital tarifflimit
limit4507 •• Subject to
to case
only • Includes
Subject case management
screening services
management •• Maxillo-facial
provided bysurgery
Maxillo-facial networksubject
surgery pharmacies
subject to
to yearly • GP
yearly sub-limit
nomination
sub-limit of
of R20 and823
R20 per
per family
specialist
823 •• Excludes
referral
family rules apply
Excludes osseo-integrated
osseo-integrated implants,
implants, all all implant-related
implant-related procedures procedures and and orthognathic
orthognathic
surgery
Radiology
surgery (advanced) – Shared limit with in-hospital advanced radiology of R21 166 per family per year • Specific authorisation required for angiography, CT scans, MDCT, coronary angiography, MUGA scans, PET scans, MRI scans and radio-isotope studies • GP nomination and specialist
referral rules apply
Radiology (basic) – X-rays and soft tissue ultrasound scans • 2 x 2D ultrasound scans provided for by maternity benefit • Sub-limit of R3 513 per beneficiary and R6 439 per family per year • GP nomination and specialist referral rules apply
Renal dialysis – Out of hospital • Includes materials and related pathology tests • Subject to pre-authorisation, managed care protocols and processes • Limited to PMBs • Subject to use of a Renal Dialysis Network DSP • If a non-network provider is voluntarily used, a co-payment of 15%
will be applied per event in accordance with network rules
Specialist services – Subject to day-to-day block benefit • Consultations, visits and all other services • Shared with GP services • 100% of Scheme Rate for non-network providers • 130% of Scheme Rate for established network specialists • Reimbursement at 200% of Scheme Rate for
procedures specified by managed care done in doctors’ rooms instead of in hospital • Reimbursement at 200% of Scheme Rate for cataract procedures performed by ophthalmologists in their rooms • Subject to GP nomination and specialist referral rules • Limit is pro-rated from join date
Key:
Key:
Key: Pre-authorisation is needed 100% of Scheme rate 100% of cost, subject to PMB legislation Subject to managed care rules Limited to PMBsYou can also read
