Beryl Benefit Guide Your 2018 - Passionate about your health - GEMS
←
→
Page content transcription
If your browser does not render page correctly, please read the page content below
Your 2018
Beryl Benefit Guide
Passionate about your health
Working towards a healthier you
This guide shows you the benefits you have access to on the Beryl option.
Keep this guide handy for quick access to your benefit information.
The Beryl option offers members comprehensive in- and out-of-hospital
benefits through a network of healthcare providers, public facilities and Out-of-hospital In-hospital A network of
benefits benefits healthcare
private hospitals.
providers
Important information to remember about the Beryl option
01 Always access a healthcare provider who belongs to the GEMS
03 If you visit a non-network GP your consultation will be paid
SB (Sapphire and Beryl) Network. This will prevent you from from the out-of-network benefit. This benefit allows three visits
having to pay for treatment or an appointment out of your own per family per year to a GP who is a non-network GP. GEMS
pocket. To find a GEMS Network doctor in your area, call the pays 80% of the Scheme rate for your three non-network
GEMS Call Centre on 0860 00 4367 or visit the GEMS website at consultations and you will need to pay a 20% co-payment from
www.gems.gov.za and click on the GEMS Network logo. your own pocket.
02 04 If you have used up your non-nominated benefit and you consult
We encourage you to nominate a GP on the Sapphire and Beryl
Network for you and your beneficiaries. You will get better health a non-nominated GP, GEMS will not pay your claim.
outcomes when you consult your nominated GP for all your
doctor visits.
05 All visits to a specialist or allied healthcare provider (such as a
physiotherapist or speech therapist) must be referred by your
nominated GP. Your nominated GP must also phone the GEMS
Call Centre and obtain pre-authorisation before you can visit a
specialist or allied healthcare provider. The Scheme will not cover
the claim if there is no pre-authorisation.
All you need to know
about the GEMS Network
The GEMS Network is made up of GPs, specialists, optometrists, dental
providers, renal dialysis providers, document-based care providers and What do I need to do before seeing my GP, specialist,
pharmacies who have agreed to provide excellent quality healthcare to dental provider, optometrist, renal dialysis provider,
GEMS members at contracted rates. document-based provider or pharmacist?
You will not be charged any co-payments or additional costs by healthcare
providers that are on the network. A network provider will only charge a Call GEMS on 0860 00 4367 or visit our website at
co-payment if your benefits are exhausted for the service or benefit you www.gems.gov.za to find out if your healthcare provider is on
want to access, or if you did not follow certain Scheme rules. For example, the GEMS Network. If your healthcare provider is not on the
if you did not get pre-authorisation for a hospital admission as required by GEMS Network, you will get the address and contact number
the Scheme rules, you will have to pay a penalty fee. All GEMS Network of the closest GEMS Network provider in your area. Always
providers will display a GEMS Network sticker in their practice window or remember to take your GEMS membership card and ID with you
door, making it easy for you to identify them. when consulting your healthcare provider.
Make sure that your GEMS Network providers are always your first port of
call. They are there to coordinate your healthcare, providing you with the What if my network doctors ask me to pay costs
best quality healthcare and value for money. from my own pocket?
Healthcare providers on the GEMS Network have committed
to providing excellent quality care to you at contracted rates
How do I find a GEMS Network provider?
and will not charge you any co-payments or additional costs.
If a healthcare provider on the GEMS Network wants you to
• Visit the GEMS website at www.gems.gov.za and click on pay upfront or requests you to pay from your pocket, contact
the GEMS Network logo GEMS immediately on 0860 00 4367. You should report any
• Call the GEMS Call Centre on 0860 00 4367 irregularities relating to healthcare providers on the GEMS
Network to GEMS.
All you need to know
about the GEMS Network cont.
What happens in the event of an emergency? Can I visit any optometrist and what are
the benefits?
If you need to see a GP after hours and your GEMS Network
GP is not available, you can visit the nearest medical facility. You can visit any optometrist on the GEMS Sapphire and
In emergency situations, you may use any facility. There is no Beryl Network. Please refer to the 2018 Benefit Schedule for
limit or co-payment required for emergency services. To avoid information about your optical benefits.
unnecessary out-of-pocket expenses, make sure that this is
only in the case of emergencies.
Can I go directly to a specialist without being
referred by my GP?
Can I visit any dental provider and what are
the benefits?
You must first visit a GP on the GEMS Sapphire and Beryl
Network. Your GEMS Network GP will then refer you to a GEMS
You can only visit a dentist or dental therapist on the GEMS Network specialist. The GP must call GEMS on 0860 436 777 to
Sapphire and Beryl Network. GEMS will not pay claims from a get a pre-authorisation number before you can visit a specialist.
non-network dental provider. Benefits cover basic dental work as If you do not follow the correct procedure, you will have to pay
explained in the benefit schedule. This includes fillings, pain and the specialist’s account yourself.
sepsis treatment, infection control and extractions under local
anaesthetic where clinically needed.
What kind of medicine does GEMS pay for?
What if I need to see a dental provider after hours? The Scheme pays for acute, chronic and over-the-counter (OTC)
medicine. Acute medicine is prescribed for a temporary illness,
In an emergency, you are allowed one visit per year condition or to relieve symptoms.
to your nearest dentist or dental therapist if a GEMS
Network dental provider is not available (for example, after
hours or for a condition serious enough that you need
immediate dental attention). This benefit covers emergency
extractions, pain and sepsis treatment only.
All you need to know
about the GEMS Network cont.
Chronic medicines are used over a long term to treat chronic illnesses such as asthma and diabetes. Ask your GEMS Network doctor to complete a Chronic
Medicine Application Form to get your chronic medicine authorised.
Medicine that you can get from the pharmacy without a doctor’s prescription is known as self-medicine or over-the-counter (OTC) medicine. You have a self-
medicine benefit to get medicines for ailments such as a headache, cold or an upset stomach. You can get these medicines from a GEMS Network pharmacy.
Can I get any medicine from any pharmacy? What should I do when a specialist gives me a
prescription for medicine?
Only medicine on the approved medicine list (GEMS formulary)
is covered at 100% of the Single Exit Price (SEP) plus the You must first make sure that your GEMS Network GP obtained
Professional Dispensing Fee (PDF). Going to a non-network a specialist referral from the GEMS Call Centre. You can then get
pharmacy or getting medicine that is not on the GEMS formulary the medicines from a GEMS Network pharmacy, provided that
will attract a co-payment of 30%. the medicine is listed on the GEMS formulary. The specialist can
access the GEMS formulary at www.gems.gov.za or contact
You can get acute and OTC medicine from a GEMS Network GEMS on 0860 436 777. Alternatively, the specialist may
dispensing doctor (a doctor who is allowed to supply medicine) contact your GEMS Network GP to confirm the GEMS formulary.
or from a GEMS Network pharmacy. You can get your chronic Please remember that your specialist visit must be authorised by
medicine from the GEMS Courier Pharmacy or from your nearest the GEMS Network GP first.
GEMS Network pharmacy.
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 youBERYL – In-Hospital Benefits
Prescribed minimum benefits (PMBs) – R1 041 200 per family per annum, 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) – Services rendered by DSP • Includes accommodation in a general ward, high care ward and intensive care unit (ICU), theatre
fees, medicines, materials and hospital equipment (includes bone cement for prostheses), confinements and midwives and neonatal care • Chronic medicine provided by chronic DSP • Subject to yearly hospital limit of R1 041 200 per family per year • TTO limited to 7 days • Co-payment
of R1 000 per admission if pre-authorisation not obtained
Alcohol and drug dependencies – Subject to use of DSP
Allied health services – Includes chiropractors, dieticians, homeopaths, podiatrists, phytotherapists, social workers, orthoptists, acupuncturists, Chinese medicine practitioners and registered counsellors • Subject to referral by network GP • Subject to services being related to admission
diagnosis • Managed care protocols and processes apply • Yearly limit of R2 075 per beneficiary and R3 122 per family, subject to PMBs • Sub-limit of R1 517 per family for social workers and registered counsellors
Alternatives to hospitalisation (sub-acute hospitals and private nursing) – Subject to yearly hospital limit and sub-limit of R20 823 per family per year • Includes home nursing • Includes physical rehabilitation for approved conditions • Excludes frail care and recuperative holidays
– Hospice • Unlimited, subject to PMB legislation
Blood transfusion – Includes cost of blood, blood equivalents, blood products and transport thereof • Subject to yearly hospital limit and sub-limit of R20 823 per family per year
Breast reduction – No benefit
Dental services (conservative, restorative and specialised) – Subject to list of approved services and use of day theatres and DSP hospitals • 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-related procedures and orthognathic surgery
Emergency services (casualty department) –
GP services – Consultations and visits • Subject to yearly hospital limit • Reimbursement according to Scheme-approved tariff, applicable to both caesarian and non-caesarian delivery and childbirth by a GP
Maternity (hospital, home birth and accredited birthing unit (public hospitals and designated private hospitals)) – Subject to registration on the Maternity Programme • Unlimited, subject to PMB • Includes complications for mother and newborn • Elective caesarian may be
subjected to second opinion • Includes midwife services • Co-payment of R1 000 per admission if pre-authorisation not obtained
Medical technologists – Subject to yearly hospital limit and sub-limit of R20 823 per family per year
Mental health – Accommodation, theatre fees, medicine, hospital equipment, professional fees from general practitioners, Psychiatrists and Psychologists • Subject to pre-authorisation and managed care protocols • Educational and industrial psychologists excluded • Limited to PMBs
Oncology (chemo and radiotherapy) – In and out of hospital • Includes medicine and materials • Subject to clinical guidelines used in public facilities programme • Subject to yearly hospital limit and sub-limit of R208 236 per family per year • Subject to MPL • Unlimited for PMBs
• 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
Pathology – Subject to yearly hospital limit
Physiotherapy – 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
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 to yearly hospital limit and a
sub-limit of R31 238 per family per year • Unlimited for PMBs once benefit limit is depleted • Scheme may obtain competitive quotes or arrange supply of prostheses • 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 • R500 for crutches per beneficiary per year • R5 500 for wheelchairs per beneficiary per year • R8 000 per hearing aid per beneficiary per year
• Foot orthotics and prosthetics subject to formulary • Subject to internal and external devices being related to admission diagnosis and procedure • Subject to PMBs
Radiology (advanced) – Subject to list of approved services
Radiology (basic) – Subject to yearly hospital limit • Includes 2 x 2D ultrasound scans per pregnancy
Renal dialysis – In hospital • Includes materials and related pathology tests • Subject to yearly hospital limit and sub-limit of R208 236 per family per year • Unlimited for PMBs • Subject to clinical guidelines used in public facilities programme
Specialist services – Consultations and visits • Subject to yearly hospital limit • 100% of Scheme Rate for non-network specialist • 130% of Scheme Rate for network specialist • Reimbursement according to Scheme-approved tariff
Surgical procedures (including maxillo-facial surgery) – Subject to yearly hospital limit • Subject to case management • Maxillo-facial surgery subject to yearly sub-limit of R20 823 per family • Excludes osseo-integrated implants and orthognathic surgery
Key:
Pre-authorisation is needed 100% of Scheme rate 100% of cost, subject to PMB legislation Subject to managed care rules Limited to PMBsBERYL – Out-of-Hospital Benefits
Personal Medical Savings Account (PMSA) – No PMSA
Allied health services – Includes chiropractors, dieticians, homeopaths, podiatrists, phytotherapists, social workers, registered counsellors and Chinese medicine practitioners • Subject to referral by network GP • Yearly limit of R2 017 per beneficiary and R3 033 per family • Sub-limit
of R1 517 per family for social workers and registered counsellors
Audiology, occupational
SAPPHIREtherapy and speech therapy – Subject
– In-Hospital Benefitsto referral by network GP • Included in allied health services benefit limit, unless PMB
Block benefit (day-to-day benefit) – No block benefit
SAPPHIRE
SAPPHIRE –– In-Hospital
In-Hospital
Prescribed
Circumcision – Subject to useminimum
Benefits
Benefits
of networkbenefits (PMBs)
GP • Global fee of– R1
R208
421237
perper family perwhich
beneficiary, annum, subjectalltorelated
includes PMB legislation • Service provided
costs of post-procedure care by DSPmonth
within • PMBs
of override
procedureall•benefit limitationsbenefit only
Out-of-hospital
Contraceptives Yearlybenefits
(oral, hospital(PMBs)
insertables, benefit –– (public
injectables hospitals, GEMS-approved private hospitals, registered unattached by theatres, dayoverride
clinics andbenefit psychiatric facilities) – Includes accommodation in a general ward, high care ward and intensive care unit (ICU), theatre fees, medicines, materials
Prescribed
Prescribed minimum
minimum benefitsequipment
and hospital (PMBs) R208 and
R208
(including
237
237bone dermal)
per
per family
family
cementper
– per
No benefit,
annum, unless
forannum,
prostheses)
subject
subject PMB
to PMB
PMB legislation
andtoneonatal legislation
care • Service
•• Service
Service provided
provided
provided byby DSP
DSP
DSP • PMBs
• •Chronic override all
PMBs medicine allprovided
benefit by limitations
limitations
chronic DSP • Subject to yearly hospital limit of R208 237 per family per year • TTO limited to 7 days • No limit per maternity confinement
Dental servicesbenefit
Yearly (conservative and restorative hospitaldentistry
limit and including acute medicine) – unattached
Yearly hospital (public hospitals, GEMS-approved private hospitals, registered to listtheatres, day
day clinics and psychiatric
Subject of•approved services and use DSP facilities)
perofadmission –– Includes
– Examinations andobtained
preventative treatment • 2 treatment events per beneficiary per year theatre – Conditions with pain and
hospital benefit event, (public
but subject hospitals,
to yearly GEMS-approved private
registration hospitals,
on Scheme’s registered Maternityunattached
Programme theatres, Co-payment clinics of R1 and000 psychiatric facilities) Includes accommodation
if pre-authorisation not
accommodation in
in aa general
general ward,ward, high
high care
care ward
ward and and intensive
intensive care
care unitunit (ICU),
(ICU), theatre fees, fees, medicines,
medicines, materials
materials
sepsis • 2 events
and per beneficiary per year – Fillingsand • Unlimited at DSP Clinically
–provided indicated dental services including extraction and emergency roothospital
canal procedure, intra-oral radiography • •1 TTO
eventlimited
per beneficiary per year – Emergency non-
and hospital
hospital equipment
equipment Alcohol
(including
(including
and drug
bone
bone cement
cement
dependencies
for
for prostheses)
prostheses)
– provided
Subject and
tothat
PMBs,
neonatal
neonatal care
care •• Service
pre-authorisation, Service provided
managed
by
by DSP
DSP
careX-ray
•• Chronic
protocols Chronic
and
medicine
medicine
theadmission
use of
provided
provided by
by chronic
chronic DSP
DSP •• Subject
Subject to
to yearly
yearly hospital limit
limit of
of R208
R208 237
237 per
per family
family per
per year
year • TTO limited to
to 77 days
days •• No
No limit
limit per
per maternity
maternity confinement
confinement
DSP visit
event, but •subject
Limited to toyearly
1 event per
hospital beneficiary
limit and per year,
registration on Scheme’s panoramic
Maternity X-rays
Programme are limited
• to one
Co-payment of every
R1 000 three
per years pera beneficiary
DSP
if • 4 bitewing
pre-authorisation not X-rays per beneficiary per year • Fluoride treatment excluded for beneficiaries older than 16 years – Dentures and specialised
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
dentistry • Limit of R3 434
Allied health per services
beneficiary per year chiropractors, dieticians, homeopaths, podiatrists, phytotherapists, social workers, orthoptists, acupuncturists and Chinese medicine practitioners • Limited to PMBs • Subject to referral by network GP and services being related to admission diagnosis
– Includes
Alcohol
Alcohol and drug
drug dependencies
andassistance dependencies – Subject to
to PMBs, pre-authorisation, managed care protocols
protocols and the
the use of
of aa legislation
DSP
Emergency (road and–air) Subject– Subject PMBs, to use pre-authorisation,
of emergency services managed DSP care • Unlimited, and
subject use
to PMB DSP
Allied
Allied health
health services
services –– Includes chiropractors, dieticians, homeopaths, podiatrists, phytotherapists, social workers, orthoptists, acupuncturists and Chinese medicine practitioners •• Limited to PMBs •• Subject to
to referral by
by network GP and
and services being related to to admission diagnosis
General Practitioner (GP) services
Alternatives Includes – Consultations
chiropractors,
to hospitalisation dieticians,
(sub-acute homeopaths,
and approved hospitals podiatrists,
minor and procedures phytotherapists,
private at nursing)
network–GP social
• Unlimited
Subject workers,
to yearly orthoptists,
• hospital
Reimbursement limitacupuncturists
andatsub-limit
200% ofof and Chinese
Scheme
R20 823Rate medicine
per for practitioners
diagnostic
family per yearprocedures Limited
• Excludes frailtocare
performedPMBs Subjecthome
•inIncludes
doctors’ referral
rooms instead
nursing network GP
of in hospital
– Hospice services
• –100% being of related
Emergency cost, medical admission
subject PMBdiagnosis
toconditions and
legislation
involuntary use of non-network GP for PMBs • Unlimited, subject to PMB legislation – Voluntary use of non-network GP • Any out-of-hospital visit to non-network GP • 80% of Scheme Rate (20% member co-payment) • Limited to 3 visits per family per year and R1 030 per
Alternatives to Blood transfusion – Includes cost of blood, blood equivalents, blood products and transport thereof
event
Alternatives to hospitalisation
hospitalisation (sub-acute (sub-acute hospitals hospitals and and private
private nursing)nursing) –– Subject
Subject to to yearly
yearly hospital
hospital limit limit andand sub-limit
sub-limit of of R20
R20 823823 per per family
family perper year year •• Excludes
Excludes frailfrail care
care •• Includes
Includes home home nursing
nursing –– Hospice
Hospice •• 100% 100% of of cost,
cost, subject
subject to to PMB
PMB legislation
legislation
GP network
Blood transfusionextender Breast
– reduction
benefit
Includes – Noof–benefit
cost No benefit
blood, blood equivalents, blood products and transport thereof
Blood transfusion – Includes cost of blood, blood equivalents, blood products and transport thereof
HIV infection, AIDS
Breast Dentaland services
related illness – Pre-exposure
(conservative, restorativeprohylaxisand included
specialised) – Only
for high riskapplicable
beneficiaries • Subject to with
to beneficiaries the Scheme’s
severe trauma, managed care protocols
impacted third molars andorregistration
under the age on theof 6HIV Disease
years Management
• Subject to yearlyProgramme
hospital limit and out-of-hospital dentistry limit • Excludes osseo-integrated implants, all implant
Breast reduction
reductionrelated –– No
No benefit
benefit
Infertility – Subject to useprocedures,
of DSP orthognathic surgery and specialised dentistry • Subject to list of approved services and use of day theatres and DSP hospitals
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 ofof 66 years
years •• Subject
Subject to to yearly
yearly hospital
hospital limit
limit and
and out-of-hospital
out-of-hospital dentistry
dentistry limit
limit •• Excludes
Excludes osseo-integrated
osseo-integrated implants, implants, all all implant
implant
Maternity (ante- Emergency
related and post-natal servicescare)(casualty
– 100% ofdepartment) Scheme Rate paid from risk,list if registered on Maternityand Programme • Subject to: referral hospitals
from DSP/network GP, Maternity Programme protocols, Managed Care Protocols and processes and PMBs OR 100% of Scheme Rate paid
related procedures,
procedures, orthognathic
orthognathic surgery surgery and and specialised
specialised dentistry
dentistry •• Subject Subject to to list ofof approved
approved servicesservices and use use of of day
day theatres
theatres and and DSPDSP hospitals
from maternity-related out-of-hospital
GP services benefits specified
– Consultations and visits in Annexure
• SubjectCto(Beryl) yearlyofhospital
the GEMS limitRules, if not registered
• Reimbursement on Maternity
according Programme • Subject
to Scheme-approved tariff to
filePMBsfor maternity •confinement,
(Kindly contact GEMS totoobtain
applicable both more
caesariandetailand
on the consultationsdelivery
non-caesarian and benefits that may be funded under the GEMS Maternity
Emergency
Programme) services
Emergency services (casualty (casualty department)
department) ––
GP services Maternity (hospital, home birth and accredited birthing unit (public hospitals and designated private hospitals)) – Subject to registration on the Maternity Programme • Elective caesarian may be subject to second opinion • Hospitalisation in designated private hospitals for
Medical
GP and––surgical
services Consultations
Consultations appliances and and••prostheses
visits
and complications
visits Subject
Subjectforto – Includes
yearly
tonewborns
yearly hospital
hospital limit aids,
hearing • Reimbursement
mobility scooters, according to
to Scheme-approved
wheelchairs, oxygen cylinders, tariffnebulisers,
file for
for maternity
glucometers,confinement,
colostomy applicable to
to both
kits, diabetic caesarian
equipment,
caesarianfoot and non-caesarian
andorthotics delivery
and external prostheses • In and out of hospital • Subject to prescription by a network
post-discharge limitedlimit to 6• weeks
Reimbursement
• Includesaccordingmidwife services Scheme-approved
• Co-paymenttariff of R1 file000 maternity
per admission confinement, applicable
if pre-authorisation not both
obtained non-caesarian delivery
GP • Subject
Maternity to yearlyhome
(hospital, hospital limit andaccredited
birth sub-limit ofbirthing R10 412unit per(public
family per year • Shared sub-limit with in-hospital prosthetics of R4 to 394 for foot on orthotics and prosthetics with•aElective
sub-limit of R1 255 forbeorthotic shoes, foot inserts and levelers per beneficiary per year • Foot orthotics
Maternity (hospital,
and prosthetics Medical
subject home birth and
technologists
to formulary and accredited
• R500 – Includes
for crutchesbirthing perunit
materials (publicper
• Limited
beneficiary
hospitals
hospitals
to PMBs
year ••R5
and
and
Subject
500
designated
designated
to event
for wheelchairs
private
private
pre-authorisation
hospitals))
perhospitals))
beneficiary
–– Subject
Subject
per year •toR8
registration
registration on the
000 per hearing the Maternity
Maternity Programme
Programme
aid per beneficiary per•year
Elective caesarian
caesarian
• Bilateral
may
mayaids
hearing be subject
subject
every 36
to second
second •opinion
to months opinion
Subject
•• Hospitalisation
Hospitalisation
to PMBs
in
in designated
designated privateprivate hospitals
hospitals forfor
post-discharge
post-discharge complications
complications for for newborns
newborns limited limited to to 66 weeks
weeks •• Includes
Includes midwifemidwife services
services •• Co-payment
Co-payment of of R1R1 000000 per per admission
admission ifif pre-authorisation
pre-authorisation not not obtained
obtained
Mental health (Consultations,
Mental– health assessments, treatment and/or counselling by GP, Psychiatrist and Psychologist) – Subject
Includes– materials
Accommodation, theatre fees,• medicine, to use of network GPand andPsychologists
specialist network • Subject to yearly hospital andlimit and combined with out-of-hospital
• Educational sub-limit of R9psychologists
460 per family per year,• Limited to PMBs
Medical
Medical technologists
technologists •• Limited to
to PMBs • Subject to hospital
event equipment,
event pre-authorisation
professional fees of General Practitioners, Psychiatrists • Subject to pre-authorisation managed care protocols and industrial excluded
unless PMB • Limited to–1Includes individualmaterials
psychologist Limited
consultation PMBsand Subject
1 grouptopsychologist pre-authorisation
consultation per day • Educational and industrial psychologists excluded • All limits are subject to PMBs
Mental
Optical health
Mental health
services –– Accommodation,
(eye examinations, theatre fees,
frames, medicine,
lenses, contact hospital equipment, professional or fees
fees of of General Practitioners, Psychiatrists and Psychologists •• Subject to
to pre-authorisation andof managed • 1care protocols •• Educational and
and industrial psychologists excluded
and a ••pair
Limited to PMBs
Accommodation,
Oncology (chemo theatre
and fees, medicine,
radiotherapy) – In andlenses
hospital out of(permanent
equipment, professional
hospital • Includes disposable) General
medicine and
and acute
Practitioners,
materials medicine)
Psychiatrists
• Subject – Subject
to and Psychologists
to use
clinical of optometry
guidelines Subject
used network
in publicpre-authorisation
and approved
facilities and
andlistMPL managed
frames
• Excludes care
eyenewprotocols
examination Educational
per beneficiary
chemotherapeutic industrial
medicinesper benefit psychologists
that have yearnot excluded
• 1demonstrated
frame aLimited toadvantage
of either
survival PMBs
single of more than
vision or bifocal lenses 3 months OR 4inboxes advanced of disposable
and metastatic contactsolid lenses organOR malignant
1 set of permanent
tumours unless contactpre-authorised
lenses • Limited to R1 371 per beneficiary every second year • Acute medicine prescribed by network GP and subject to formulary • Benefits not pro-rated • Post-cataract surgery, optical
Oncology
PMB benefit(chemo
Oncology limited to
(chemo and
and theradiotherapy)
cost of a bifocal––lens
radiotherapy) In
In and not out
and moreof ofthan R1 061
hospital for both medicine
•• Includes lens and frame,and with a sub-limit
materials •• Subject of R210to for theguidelines
to clinical frame • Either usedspectacles
in
in public or contactand
facilities lenses
MPLwill
MPL be fundednew
•• Excludes in anchemotherapeutic
optical appliance cycle, medicinesnot both that•have
that Includes
not tinted
not lenses upaa tosurvival
demonstrated 35% tint for albinism
advantage of and proven
of more than
33photophobia, subject Organ toand and tissue transplants
pre-authorisation –outSubject hospital
totint Includes
pre-authorisation medicine
andlenses and guidelines
clinical materials Subject
used in public clinical
facilitiesguidelines
• Subjectused to PMBs public
• Includes facilities and
materials Excludes new chemotherapeutic medicines have demonstrated survival advantage more than
months
months in in advanced
advanced and metastatic
metastatic solid solid• organ
Excludes
organ variabletumours
malignant
malignant tumours andunlessphotochromic
unless pre-authorised
pre-authorised
Orthopedictissue
Organ Disease PathologyManagement – SubjectProgrammeto yearly – Negotiated
hospital limit rate • Subject to managed care protocols and processes
Organ and and tissue transplants
transplants –– Subject Subject to to pre-authorisation
pre-authorisation and and clinical
clinical guidelines
guidelines used used in in public
public facilities
facilities •• SubjectSubject to to PMBs
PMBs •• Includes
Includes materials
materials
Pathology
Pathology – Subject
–– Subject Physiotherapy
to
to referral
yearly by –
network
hospital Post-hip,
limit practitioner
knee andand list
shoulder of approved
replacementtests • Tests
or requested
revision by
surgery specialist
physiotherapy are covered • 10 subject to the list
post-surgery of approved visits
physiotherapy services,
(sharedif referred by DSP Practitioner
with out-of-hospital visits)and
up the
to avisit
limitisofpre-authorised • Unlimitedper
R5 021 per beneficiary • Pre-authorisation
event used withinrequired 60 days for certain examinations
of surgery
Pathology Subject to yearly
as per the Managed Care Radiology Request Form hospital limit
Physiotherapy 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 to the yearly hospital limit and
Physiotherapy –– aPost-hip, Post-hip,
Subject
sub-limit toknee
knee
referral
of R23
and
and byshoulder
790 shoulder
network
per family
replacement
replacement
practitioner
per year •• Included
or
or revision
Bone revision surgery
surgery
in allied
cement paidhealth
from
physiotherapy
physiotherapy
services benefit
in-hospital
•• 10
benefits 10
limit post-surgery
post-surgery
• unless
SharedPMB
physiotherapy
physiotherapy
sub-limits –visits
visits (shared
(shared
Post-hip,
with out-of-hospital kneewith
withand
prosthetics
out-of-hospital
out-of-hospital
shoulder visits)
visits) up
replacement
and appliances upR4
of
to
to aa394
orlimit
limit of R5
foroffoot
revision 021
021 perper beneficiary
R5 physiotherapy
orthotics • 10per
beneficiary
and prosthetics per event
event usedphysiotherapy
with aused
post-surgery within
withinof60
sub-limit 60R1days
days
255
of
offorsurgery
visits surgery
(shared
orthotic with
shoes, in-hospital visits)
foot inserts anduplevelers
to a per beneficiary
Prostheses
limit of R5 021
Prostheses –– Covers
perper
Covers beneficiary
year. Footper
prostheses
prostheses andevent
orthotics
and used
surgically within
implanted
and prosthetics
surgically implanted 60 dayssubjectof surgery
internal
internal todevices,
formulary
devices, including
• R500all
including allfortemporary
crutches prostheses
temporary per beneficiary
prostheses and
and perall
all accompanying
year • R5 500temporary
accompanying for wheelchairs
temporary or
or permanent
per beneficiary
permanent devices
devicesper used
used yearto
to assist
•assist
R4 500 with
withperthe guidance,
thehearing
guidance, aidalignment and
and delivery
per beneficiary
alignment per yearof
delivery of•internal
Subjectprostheses
internal to internal ••and
prostheses Subject
external
Subject to
to the yearly
devices
the hospital
yearlybeing
hospital limit
limittoand
related admission diagnosis
and
aaPrescribed
sub-limit
sub-limit of R23
ofmedicine
R23 and 790 per
per family
and
790procedure injection
family •per
per year
material
Subject
year ••toBone
Bone cement
cement paid
– Prescribed
PMBs paid and from in-hospital
administered
from in-hospitalby benefits •• Shared
a professional
benefits Sharedlegally sub-limits
sub-limitsentitled with
withtoout-of-hospital
do so • Subjectprosthetics
out-of-hospital and
and appliances
to MPL • Prescription
prosthetics appliances by aof R4
R4 394 394 for
ofspecialist foot
is only
for orthotics
orthoticsifand
foot covered prosthetics
referred
and by network
prosthetics with
with aaGPsub-limit
and theof
sub-limit R1
R1is255
ofvisit for
for orthotic
orthotic shoes,
pre-authorised
255 shoes, foot – Acute
foot inserts
inserts and
and levelers
medical per
per beneficiary
conditions
levelers • Subject
beneficiary
per year.
year. Foot
Foot•orthotics
to formulary Unlimited and at prosthetics
network subject
dispensing to
toGPformulary
or • R500 for crutches per
per beneficiary per
per year •• R5R5 500 GPfor wheelchairs per
per beneficiary per
per yearyear •• medicine
R4
R4 500 500 per or hearing
voluntaryaid per
perofbeneficiary per year
year •• Subject to
to internal
– Chronic and
and external
medical conditions devices being
beingtorelated
(limited CDL and to
to admission
DTP PMBdiagnosischronic
per
and procedure
orthotics
Radiology
•• Subject
and prosthetics
(advanced) subject– Subject to network
formulary pharmacy
list of•approved
R500 • Subject
for services
crutches to prescription
beneficiary by network
year 500 • 30%
for co-payment
wheelchairs on out-of-formulary
beneficiary per hearing aiduse non-network
beneficiary per pharmacy Subject internal external devices related admission diagnosis
conditions)
and procedure • Subject
Subject to toto PMBs
prior
PMBs application, approval, formulary and use of DSP practitioner • Subject to prescription by network GP • Unlimited, except for the R527 limit per family per year for homeopathic medicine • 30% co-payment on out-of-formulary medicine or voluntary use of
non-network pharmacy
Radiology Radiology (basic)list
– Self-medicine – Subject
(OTC) to • Toyearly hospital limit
be obtained for minor• Includes
ailments 2 x •2DSubjectultrasound scans per
to formulary andpregnancy
use of network pharmacy • Limited to R61 per event, 5 events and R312 per family per year • Only schedule 0, 1 and 2 covered
Radiology (advanced)
(advanced) –– Subject Subject to to list of of approved
approved services services
Preventative
Radiology (basic)care services
Renal
–– Subjectdialysis– –
Payable In from
hospital risk
• • Includes
Includes Influenza
materials and vaccination,
related HPV
pathology vaccination
tests • and
Subject Pneumococcal
to clinical vaccination
guidelines used •inInfluenza vaccination and HPV vaccination (for female beneficiaries) limited to 1 per year unless indicated otherwise • Pneumococcal vaccination once
public facilities
Radiology
every 5 years (basic) Subject to
for beneficiaries toatyearly
yearly hospital limit
risk •hospital
Subjectlimit
•• Includes
to managed Includes care
22 xx 2D2D ultrasound
protocols ultrasound scans
scans per
and processes per•pregnancy
pregnancy
Includes screening services provided by network pharmacies
Renal dialysis Specialist
–– In services – Consultations 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
Renal dialysis
Screening services In hospital
– Serum
hospital •• Includes
Includes
cholesterol, materials
materials
bone densityand
and related
related pathology tests
tests •• Subject
pathology liquid-based
scan (including Subject to
to clinical
cytology), papguidelines
clinical guidelines used
used in
smear, prostate-specific in public
public facilities
facilities glaucoma screening, serum glucose, occult blood, Thyrotropin (TSH) for neonatal hypothyroidism, mammogram and other screening according to evidence-
antigen,
Specialist
based standardservices Surgical
practice procedures
–– Consultations
• Pap smears (including
include maxillo-facial surgery) – Subject to yearly hospital limit • Subject to case management • Maxillo-facial
Includes surgery subject to yearly sub-limit ••ofReimbursement
R20pharmacies
823 per family • Excludes osseo-integrated implants, all implant-related procedures and orthognathic
Specialist services surgery Consultations and
and visits ••liquid-based
visits 100%
100% of cytologyRate
of Scheme
Scheme • Neonatal
Rate for Hypothyroidism
for non-network
non-network providers
providers screening130%test
•• 130% of – TSH (Thyrotropin)
of Scheme
Scheme Rate
Rate for tariff 4507
for established
established only •specialists
network
network specialists screening
Subjectservices
•• Subject to yearlyprovided
to yearly hospital in
hospital network
limit
limit Reimbursement according
according to to Scheme-approved
Scheme-approved tariff tariff file
file
Radiology (advanced)(including
Surgical – Shared with in-hospital surgery)
Surgical procedures
procedures (including maxillo-facial maxillo-facial surgery) –– Subject
advanced radiology to limit of R31 238 per family per yearcase management • Maxillo-facial surgery subject to yearly sub-limit of R20 823 per family • Excludes osseo-integrated implants, all implant-related procedures and orthognathic
Subject to yearly yearly hospital
hospital limitlimit •• Subject
Subject to to case management • Maxillo-facial surgery subject to yearly sub-limit of R20 823 per family • Excludes osseo-integrated implants, all implant-related procedures and orthognathic
Radiology (basic) – Subject to referral by network GP and list of approved services • 2 x 2D ultrasound scans per pregnancy provided for by maternity benefit • Examinations requested by specialist are covered subject to list of approved services, if referred by network GP and the visit
surgery
surgery
is pre-authorised • Unlimited • Pre-authorisation required for certain examinations as per the Managed Care Radiology Request Form
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 – 100% Scheme Rate for non-network providers • 130% Scheme Rate for network specialists • Subject to network GP referral and list of approved services for radiology and pathology and treatment plans care protocols • Limited to 5 consultations or R3 747 per
family per year or 3 consultations or R2 498 per beneficiary per year • 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
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
