Emerald Benefit Guide - Your 2018 Passionate about your health - GEMS
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Your 2018
Emerald Benefit Guide
Passionate about your health
Working towards a healthier you
This guide shows you what benefits you have access to on the Emerald option. Keep this guide on hand for quick access to your benefit information.
The Emerald option provides access to the providers of your choice, subject to benefits and Scheme rules.
Important information to remember about the Emerald option
01 03
The Ruby, Emerald and Onyx (REO) Network is made up of General We encourage you to nominate a GP on the GEMS REO GP
Practitioners (GP), Dental Providers, Specialists, Renal dialysis Network, who you will consult for all your doctor visits. However,
Providers, Document-based care Providers and Pharmacies who penalties will not apply if you do not nominate a GP. Your nominated
have agreed to charge the contracted rate and follow GEMS GP has the best understanding of your health and treatment
Network and managed care rules. history and will be in the best position to determine whether a
specialist referral is necessary. This will help to ensure that duplicate
diagnostic tests are not done, medicine errors are reduced, access
02 to services is enhanced, and hospital admissions and re-admissions
To find a GEMS Network provider in your area, visit the GEMS are reduced. In turn, you will receive the best possible healthcare
website at www.gems.gov.za and click on the GEMS Network from the right healthcare provider, with the right skills, at the right
logo or call the GEMS Call Centre on 0860 00 4367. time and have better control over how your benefits are managed.
04
Always get a referral from your nominated GP before you consult a specialist. Remember to ask for a specialist on the GEMS Specialist Network if
you need to consult a Paediatrician, Psychiatrist, Obstetrician, Gynaecologist or a Physician (which also includes Pulmonologists [lung specialist],
Gastroenterologists, Neurologists, Cardiologists and Rheumatologists). Network GPs and Specialists have agreed to charge contracted rates so that
you will not have to pay 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.
05
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-isotope
studies, in-hospital physiotherapy, ambulance transportation 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 – In-Hospital Benefits Prescribed minimum benefits (PMBs) – Unlimited, subject to PMB legislation • Service provided by DSP • PMBs override all other benefit limitations Yearly hospital benefit (public hospitals, GEMS-approved private hospitals, registered unattached theatres, day clinics and psychiatric facilities) – Unlimited • 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 (including bone cement for prostheses) and neonatal care • 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 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 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 • 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 Maternity (hospital, home birth and accredited birthing unit (public hospitals and designated private hospitals)) – Shared with GP services, where not accessed under 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 from 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 • 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 • Subject to PMBs 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 – Limited to R4 757 per beneficiary per year – 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 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 • 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 • 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 • Includes related pathology tests done at network provider • 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 • 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 • 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 – 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 SAPPHIREtechnology • Sub-limit – In-Hospital of R1 726 per beneficiaryBenefits and R3 450 per family per year
Block
SAPPHIRE benefit (day-to-day
–– In-Hospital benefit) – Benefits
Out-of-hospital GP and specialist services, physiotherapy, maternity, audiology, occupational therapy, speech therapy, pathology and medical technology • Limited to R4 400 per beneficiary and R8 804 per family per year • Benefit is pro-rated from join
SAPPHIRE
date In-Hospital
Prescribed minimum benefits Benefits (PMBs) – R208 237 per family per annum, subject to PMB legislation • Service provided by DSP • PMBs override all benefit limitations
Prescribed
Circumcision minimum Yearlybenefits
– Global hospital
of R1 (PMBs) benefit –– (public
R208 hospitals, GEMS-approved private hospitals, registered withinunattached by theatres, dayoverride
ofclinics and psychiatric facilities) – Includes accommodation in a general ward, high care ward and intensive care unit (ICU), theatre fees, medicines, materials
Prescribed minimum fee
benefits
and hospital
421
(PMBs)
equipment R208 237
per beneficiary,
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dermal) – Subject
Yearly hospital (public hospitals, yearlyGEMS-approved and private hospitals, registered unattached theatres, day
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toonformulary • Subject to acute medicine benefit limit •ofSub-limit of R2 677 facilities)
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• Co-payment clinicsR1 and000 psychiatric
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osseo-integrated R208 237 per
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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
general anaesthesia
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for children under the –age toofPMBs,
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homeopaths, • 200%
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–– Subject
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and the
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Includes
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subjecthomeopaths,
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andR20Chinese
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• Includes referral
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– Hospice services
• 100% being of related
cost, subject admission
to PMBdiagnosis
legislation
General Practitioner (GP) services – Subject to day-to-day block benefit • Limited to R4 400 per beneficiary and R8 804 per family per year shared with specialist services, physiotherapy and maternity • Covers consultations and approved minor procedures at GP • Limit is pro-rated •
Alternatives to Blood
hospitalisationtransfusion (sub-acute – Includes cost
hospitals of blood, blood equivalents, blood products and transport thereof
Alternatives
Reimbursement to athospitalisation
200% of Scheme (sub-acute
Rate for procedures hospitals and and private
private
specified nursing)
nursing)care
by managed –– Subject
performed
Subject to
to yearly hospital
in doctors’
yearly hospitalrooms limit
limit and and sub-limit
instead of
of R20
of in hospital
sub-limit R20 823823 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
GP
Blood network
transfusion extenderBreast
– reduction
benefit
Includes –
cost For of –beneficiaries
No benefit
blood, blood with chronic
equivalents, conditions
blood productsregistered
and on disease
transport management
thereof programme • 2 additional GP consultations at a network GP once block benefit is exhausted • Payable from risk
Blood transfusion – Includes cost of blood, blood equivalents, blood products and transport thereof
HIV infection, AIDS
Breast Dentaland services
related illness (conservative,– Subject restorative
to PMBs andand managedspecialised) – Only applicable
care • Pre-exposure prophylaxis included for
to beneficiaries withhigh risk beneficiaries
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
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, restorative and specialised) – Only applicable to beneficiaries with
with severe trauma,
trauma,•impacted third molars or
or under
under the age
age of of 66 Managed
years
years •• Subject to
to yearly hospital limit
limit and out-of-hospital dentistry limit •• Excludes osseo-integrated implants, all
all implant
Maternity
related (ante-(conservative,
procedures, Emergency
and post-natal
orthognathic
restorative
services care)(casualty
surgery – 100% and of specialised)
department)
Scheme Rate––paid
Only from applicable
risk, if to beneficiaries
registered onservices
Maternity severe Programme impacted
Subject to: third molars Programme
Maternity theprotocols, Subject
Care Protocols yearlyand hospital
processes and
andout-of-hospital
PMBs dentistry
OR 100% limit of ExcludesRate
Scheme osseo-integrated implants,
paid from day-to-day block implant
benefit,
related procedures,
if not registered on the orthognathic surgery and
Maternity Programme and•specialised
specialised
Subject to PMBs
dentistry
dentistry •• Subject Subject
• (Kindly
to
to list
list of
of approved
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GEMS toservices
obtain more
and
and use use
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and DSP
consultations DSPand hospitals
hospitals
benefits that may be funded under the GEMS Maternity Programme)
Emergency GP services
services (casualty – Consultations
department) and
–– visits • Subject to yearly hospital limit • Reimbursement according to Scheme-approved tariff file for maternity confinement, applicable to both caesarian and non-caesarian delivery
Emergency
Medical andservices surgical(casualty
appliances department)
and prostheses – Includes hearing aids, wheelchairs, mobility scooters, oxygen cylinders, nebulisers, glucometers, colostomy kits, diabetic equipment, foot orthotics and external prostheses • In and out of hospital • Shared with in-hospital internal prosthesis
GP
limitservices
of R40 010– Maternity
per family per(hospital,
year • home
Sub-limit birth
of R15 and 611accredited
for medical birthing
and unitappliances
surgical (publicaccordinghospitals
per family and perdesignated
year • Shared private
sub-limithospitals))
withmaternity – Subject
in-hospital to registration
prosthetics of R4 394 on the
forbothMaternity
foot orthotics Programme
and • Electivewith caesarian
sub-limitmay be255subject to second opinion • Hospitalisation
and levelersin perdesignated private hospitals for
Consultations
GP services – Consultations post-discharge
and
and visits
visits
complications
•
• Subject
Subject to
to yearly
yearly
forformulary
newborns
hospital
hospital limit
limit • Reimbursement
6• weeks
Reimbursement according to
to Scheme-approved
Scheme-approved tariff
tariff file for
file000
for maternity confinement,
confinement, applicable
applicable to
to both caesarian
caesarian andprosthetics
and non-caesarian
non-caesarian adelivery
delivery of R1 for orthotic shoes, foot inserts beneficiary
per year • Foot orthotics and prosthetics subject to • limited
R500 for to crutches • Includes
per beneficiary midwife
per yearservices• R5•500 Co-payment
for wheelchairsof R1 per admission
per beneficiary per year if pre-authorisation
• R8 000 per hearing not obtained
aid per beneficiary per year • Bilateral hearing aids every 36 months • Subject to PMBs
Maternity
Maternity (hospital,
(hospital, home birth
birth and
hometechnologists and accredited
accredited birthing
birthing unit
unit (public
(public to hospitals
hospitals and
and designated
designated private
private hospitals))
hospitals)) –– Subject Subject to to registration
registration on on the the Maternity
Maternity Programme
Programme •• Elective Elective caesarian
caesarian may may be be subject
subject to to second
second opinion
opinion •• Hospitalisation
Hospitalisation in in designated
designated privateprivate hospitals
hospitals for for
Mental health (Consultations,
post-discharge Medical assessments, – Includes treatmentmaterials and/or• Limitedcounselling PMBsby• GP, Subject Psychiatrist and Psychologist)
to event pre-authorisation – Consultations, assessments,not treatments and/or counselling by GPs, psychiatrists, psychologists • If out-of-hospital treatment offered as alternative to hospitalisation,
post-discharge complications
complications for for newborns
newborns limited limited to to 66 weeks
weeks •• Includes
Includes midwife midwife services
services •• Co-payment
Co-payment of of R1R1 000 000 per per admission
admission ifif pre-authorisation
pre-authorisation not obtained obtained
then hospital benefits will
Mental– healthapply • Shared
– materials with
Accommodation, in-hospital mental
theatre health
fees, medicine, limit of R17 639 per
hospitalpre-authorisation family per year • Sub-limit of R5 231 for out-of-hospital psychologist consultations • Limited to 1 individual psychologist consultation
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 and 1 group psychologist consultation per day • Educational and
Medical
industrialtechnologists
Medical technologists
psychologists excluded – Includes
Includes • All limits are•• subject
materials Limited
Limitedtoto PMBs
PMBs •• Subject
toPMBs Subject to to event
event pre-authorisation
Mental
Opticalhealth
Mental services
health –– Accommodation,
(eye examinations,
Accommodation, theatre
theatre frames,
fees,
fees, lenses, contact
medicine,
medicine, hospital
hospital lenses (permanent
equipment,
equipment, professional
professional or fees
disposable)
fees of Generaland
of General acute medicine)
Practitioners,
Practitioners, – All services
Psychiatrists
Psychiatrists and
and Psychologists
included in••benefit
Psychologists Subject
Subject to
to pre-authorisation
subject to optical managed
pre-authorisation and managed
and caremanaged care
programme
carenew protocols
• Sub-limit
protocols •• Educational
of R2 210 per
Educational and industrial
andbeneficiary
industrial psychologists
every second benefit
psychologists excluded
excluded •• Limited
year and yearly
Limited to PMBs
limit
PMBsof of more than
toadvantage
R4 417 per familyOncology • Frames limited (chemo to and R1 289 radiotherapy)
• Limited to 1– eye In and out of hospital
examination • Includes
per beneficiary per medicine
year • 1 frame and materials
and 1 pair•ofSubject lenses to perclinical
beneficiary guidelines
every second used inyear
public
• Nofacilities
limit willand MPL
be applied • toExcludes
the number ofchemotherapeutic
contact lenses thatmedicines may be renderedthat have to not demonstrated
a beneficiary, aside afromsurvival
the indicated
3 months in advanced and metastatic solid organ malignant tumours unless pre-authorised
financial benefit limits • Either spectacles or contact lenses will be funded in a benefit year, not both • Excludes variable tint and photochromic lenses • Benefit not pro-rated • Post cataract surgery, optical PMB entitlement limited up to the cost of bifocal lens and not more than R1 061 for both
Oncology
Oncology (chemo
(chemo and
and radiotherapy)
radiotherapy) –– InIn andand•–outout of
of hospital
hospital •• Includes
Includes medicine and materials • Subject to
to clinical guidelines used in
in public facilities and MPL
MPL ••tint Excludes new
new chemotherapeutic medicines
medicines that that have
have notnot demonstrated
demonstrated aa survival survival advantage
advantage of of more
more than
lens and frame, Organ
with and
a sub-limit tissue
of R210 transplants
for frame Includes
Subject tinted
to lenses
pre-authorisation up tomedicine
35%andtint andalbinism
for
clinical materials
guidelines and•used Subject
proven clinical
photophobia,
in public guidelines
facilitiessubject used
to pre-authorisation
• Subject to PMBs public
• Includes facilities
• Excludes andvariable
materials Excludes
and photochromic chemotherapeutic
lenses than
33 months
months in in advanced
advanced and and metastatic
metastatic solid solid organ
organ malignant
malignant tumours tumours unless unless pre-authorised
pre-authorised
Orthopedic Disease Management
Pathology – Subject Programme
to yearly – Negotiated rate • Subject to managed care protocols
hospital limit and clinical guidelines used in public facilities • Subject to PMBs • Includes materialsand processes
Organ
Organ and
and –tissue
tissue transplants
transplants –– Subject
Subject to
to pre-authorisation
pre-authorisation andper clinical guidelines usedand in public facilities • Subject to shared
PMBs •with Includes materials
Pathology Subject to day-to-day block benefit • Limit of R2 147 beneficiary per year R4 302 per family per year audiology, occupational therapy and speech therapy • Includes liquid-based cytology pap smear
Pathology –– Subject Physiotherapy
to – 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
Pathology
Physiotherapy to yearly
yearly hospital
– Physiotherapy
Subject hospital
performed limit
limit in hospital or instead of hospitalisation will be paid from in-hospital benefit • Sub-limit of R2 147 per beneficiary and R4 287 per family per year shared with GP services – Post-hip, knee and shoulder replacement or revision surgery
Physiotherapy Prostheses – Covers prostheses and surgically implanted internal devices,
to a limitincluding all pertemporary prostheses andused
allvisits
accompanying temporary
surgery or permanent devices used to assist withbeneficiary
the guidance, alignmentusedand deliverydays of internal prostheses • Subject to the yearly hospital limit and
Physiotherapy –– aPost-hip,
physiotherapy • 10 post-surgeryknee physiotherapy
and shoulder visits (shared
replacement with
or in-hospital
revision visits) upphysiotherapy
surgery of R5•021 10 beneficiary
post-surgery per event
physiotherapy within 60 days
(shared with ofout-of-hospital visits) up to aa limit of R5 021 per per event within
Post-hip,
sub-limit knee
of R23 790and shoulder
per family replacement
per year and or
• Bone revision
cement paid surgery from physiotherapy
in-hospital • 10
benefits post-surgery
• Shared physiotherapy
sub-limits with visits (shared
out-of-hospital with
prosthetics out-of-hospital
and visits)
appliances up to
of R4 •394 limit of R5
for foot 021 per
orthotics andbeneficiary
prostheticsper event aused
withbeneficiary withinof60
sub-limit 60R1days
255
of
offorsurgery
surgery
orthotic shoes, foot inserts
Prescribed
Prostheses medicine
–– Covers and
prosthesesinjection and material
surgically – Prescribed
implanted internal administered by a professional legally entitled to do so • Subject to MPL and MEL – Acute medical conditions Subject to formulary • Limit R3 528 per and R10 583 per family per year, subject to aand levelers per beneficiary
sub-limit
Prostheses
of R527 for Covers
homeopathicper year. Foot orthotics
prostheses
medicine and
per andper
surgically
family prosthetics
implanted
year • 30%subject
internal todevices,
co-payment formulary
devices, on
including
• R500all
including
out-of-formularyallfortemporary
crutches
temporary
medicine
prostheses
per•beneficiary
prosthesesIncludes
and all
all accompanying
per
andprescribedaccompanying R5 500temporary
year •maternity for wheelchairs
temporary
vitamin
or
or permanent
per •beneficiary
permanent
supplement
devices
devicesper
Homeopathic
used
used year
and
to assist
•assist
R4 500
toalternative with the
per
withmedicine guidance,
thehearing
guidance, aidalignment
excluded perunless
alignment and
and delivery
beneficiary per year
delivery
prescribed by
of
ofa•internal
Subjectprostheses
internal
network to internal–••and
prostheses
GP
Subject
external
Subject
Chronic
to
to the
the
medical
yearly
devices
yearly hospital
being
hospital
conditions •
limit
related
limit
CDL toand
admission diagnosis
and
and
aa sub-limit
sub-limit of
of R23
R23 and 790 per
per family
790procedure family •per
per year
Subject
year ••toBonePMBs
Bone cement
cement and paid from
from in-hospital
paidapproval in-hospital benefits
benefits •• Shared
Shared sub-limits
sub-limits with
with out-of-hospital
out-of-hospital prosthetics
prosthetics and
and appliances
appliances of
of R4R4 394
394 for foot
foot orthotics
forfamily orthotics and
and prosthetics
prosthetics with
with aasubject
sub-limit
sub-limit of
of R1 255
255 for
for orthotic
R1 legislation orthotic shoes,
shoes, foot
foot inserts
inserts and
and levelers
levelers per beneficiary
permedicine
beneficiary
DTP
per PMB
year. chronic conditions • Subject to prior application and use of chronic medicine pharmacy DSP • Limit of R10 583 per beneficiary and R21 310 per per year • Unlimited for PMBs, to PMB • 30% co-payment on out-of-formulary and
per year. Foot
voluntary Foot
use of
orthotics
orthotics
Radiology
and
and• prosthetics
prosthetics subject to
limit issubject
(advanced) to formulary
– Subject formulary • R500
list of•approved
R500
will befor
for crutches
crutches per
per beneficiary
beneficiary
benefit forper
per year
life year
•• R5
R5 500 500 for
for wheelchairs
wheelchairs per beneficiary
perrisk
beneficiary per
per to year
year •• R4R4 500 500 per hearing
careperandhearing aid
aid per
per beneficiary
beneficiary per
per year
year •• Subject
– Prescribed Subject
medicine
to
to internal
internal and
and external
from hospital external
stay (TTO)
devices
devices being
being related
related to
to admission diagnosis
admissionbenefit
diagnosis
and
and procedure
procedure ••non-DSP
Subject
Subject to
to
Once
PMBs
PMBs
depleted, CDL to benefit limited
services • Include threatening allergies payable from and subject managed formulary • Included in acute medicine limit
• TTO limited to 7 days and must be related to admission diagnosis and procedure • Payable from risk once acute medication benefit limit is exhausted – Self-medicine (OTC) • Payable from risk once acute medicine benefit is exhausted • Subject to formulary • Schedule 0, 1 and 2 medicines
Radiology (advanced) Radiology (basic)
–– Subject to – Subject to yearly hospital limit • Includes 2 x 2D ultrasound scans per pregnancy
Radiology
covered • Subject(advanced) to acute medicine
Subject to listbenefit
list of
of approved
limit (event
approved services
limit of R237 per beneficiary) and sub-limit of R889 per beneficiary per year and a yearly family limit of R1 421 and must be related to admission diagnosis and procedure – Contraceptives • Subject to formulary • Subject to acute
services
medicine benefit limit
Radiology Renal anddialysis
sub-limit –ofInR2 677 per
hospital beneficiary
• Includes per yearandultrasound
materials related pathologypertests • Subject to clinical guidelines used in public facilities
Radiology (basic)(basic) –– SubjectSubject to to yearly
yearly hospitalhospital limit limit •• Includes
Includes 22 xx 2D 2D ultrasound scans scans per pregnancy pregnancy
Preventative careSpecialist services services
– Payable–from risk • Includes
Consultations and Influenza
visits • 100% vaccination,
of Scheme HPVRate vaccination
for and Pneumococcal
non-network providers •vaccination
130% • Influenza
of Scheme Ratevaccination
for established and HPV networkvaccination
specialists(for female
• Subject beneficiaries) limited to
to yearly hospital 1 per
limit year unless indicated
• Reimbursement according otherwise • Pneumococcaltariff
to Scheme-approved vaccination
file once every
Renal
5 yearsdialysis
Renal dialysis –– In
for beneficiariesIn hospital
hospital
at risk•• Includes
• Subjectmaterials
Includes materials
to managed and
andcare related
related pathology
pathology
protocols and tests
tests •• Subject
processes Subject
• Includesto
to clinical
clinical guidelines
guidelines
screening services used in
in public
usedprovided public byfacilities
facilities
network pharmacies
Specialist 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, all implant-related procedures and orthognathic
Screeningservices
Specialist services–––Consultations
services Serum cholesterol,
Consultations and
and visits bone••density
visits 100%
100% scan, of
of Schemepap smear
Scheme Rate for
for non-network
Rate (including non-networkliquid-based providers •• 130%
cytology),
providers 130% of
of Scheme
prostate specificRate
Scheme for
for established
antigen,
Rate network
network specialists
glaucoma screening,
established serum glucose,
specialists •• Subjectoccult
Subject to yearly
toblood hospital
yearlytests,
hospital limit
limit •• Reimbursement
Thyrotropin (TSH) for neonatal
Reimbursement according to
to Scheme-approved
hypothyroidism,
according mammogram and
Scheme-approved tariff file
tariffother
file screening according to evidence-
surgery
based standard practice(including
Surgical • Neonatal hypothyroidismsurgery) screening test – TSH (Thyrotropin) tariff 4507 only • Includes screening services provided bysurgery network pharmacies
Surgical procedures
procedures (including maxillo-facial maxillo-facial surgery) –– Subject Subject to to yearly
yearly hospital
hospital limit limit •• Subject
Subject to to casecase management
management •• Maxillo-facial
Maxillo-facial surgery subject subject to to yearly
yearly sub-limit
sub-limit of of R20
R20 823 823 perper family
family •• Excludes
Excludes osseo-integrated
osseo-integrated implants,implants, all all implant-related
implant-related proceduresprocedures and and orthognathic
orthognathic
Radiology (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
surgery
surgery
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
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 • 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
