Ruby Benefit Guide Your 2018 - Passionate about your health - GEMS
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Your 2018
Ruby Benefit Guide
Passionate about your health
Working towards a healthier you
This guide shows you what benefits you have access to on the Ruby
option. Keep this guide handy for quick access to your benefit information.
The Ruby option offers members comprehensive in- and out-of-hospital
benefits through a Personal Medical Savings Account (PMSA), hospital plan Personal Medical
Hospital plan Block Benefit
and a Block Benefit. Savings Account
Important information to remember about the Ruby option
01 03
The Personal Medical Savings Account (PMSA) is 20% of your To find a GEMS REO Network provider in your area, visit the GEMS
contribution allocated to a savings account in the main member’s website at www.gems.gov.za and click on the GEMS Network logo
name. This is the account that pays for your out-of-hospital or day- or call the GEMS Call Centre on 0860 00 4367.
to-day medical expenses. Once you have used up all the funds in
your PMSA, your out-of-hospital claims will be paid from the limited
Block Benefit. For 2018 this benefit amounts to R1 585 per family 04
per year. You will receive an annual PMSA statement which shows
We encourage you to only consult a specialist through a referral
all transactions you made on your savings account.
from your GP. Remember to ask for a specialist on the GEMS
Specialist Network if you need to consult a paediatrician, psychiatrist,
In 2017, the Constitutional Court ruled that Personal Medical
obstetrician, gynaecologist or a physician (which also includes
Savings Accounts (PMSA) should be included as an asset of the
pulmonologists, gastroenterologists, neurologists, cardiologists and
Medical Scheme. Although members still have control over their
rheumatologists). Network GPs and specialists have agreed to bill at
PMSA, which they can use to cover out-of-hospital and day-to-day
contracted rates so that you will not have to pay any out-of-pocket
healthcare needs, they can no longer earn interest on their PMSA.
expenses for your consultations. Your day-to-day benefits will also last
This is effective from 1 January 2018.
longer if you use healthcare providers that are on the network.
02 Remember to call 0860 00 4367 to get pre-authorisation for all
The Ruby, Emerald and Onyx (REO) Network is made up of General hospital visits, out-patient visits to a hospital, MRI scans, CT scans
Practitioners (GP), dental providers, specialists, renal dialysis or radio-isotope studies, in-hospital physiotherapy, ambulance
providers, document-based care providers and pharmacies who transportation and specialised dentistry. You will receive a pre-
have agreed to charge contracted rates and follow GEMS Network authorisation number which indicates that the claim will be paid at
and managed care rules. Scheme rates.
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
• improve your sleeping habits
you 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 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.
GEMS Fitness 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
RUBY – 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 • 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, phytotherapists, social workers, orthoptists, acupuncturists and Chinese medicine practitioners • Limited to PMSA and block benefit 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 – No benefit, unless PMB Dental services (conservative, restorative and specialised) – Subject to list of approved services and use of day theatres • General anaesthesia and conscious sedation subject to managed care rules • Only applicable for beneficiaries with severe trauma, impacted third molars or under the age of 6 years • Lingual and labial frenectomies under general anaesthesia for beneficiaries under the age of 8 years, subject to managed healthcare programme • Professional fees subject to shared limit with out-of-hospital dentistry benefit of R3 200 per beneficiary per year • Excludes osseo-integrated implants, all implant-related procedures and orthognathic surgery Emergency services (casualty department) – Paid from out-of-hospital GP services for non-PMB and unauthorised events GP services – Consultations and visits • Reimbursement according to Scheme-approved tariff file, applicable to both caesarian delivery and non-caesarian delivery Maternity (hospital, home birth and accredited birthing unit (public hospitals and designated private hospitals)) – Subject to registration on the Maternity Programme prior to admission • Unlimited, subject to PMB legislation • Elective caesarian may be subject to second opinion • Includes midwife services • Co-payment of R1 000 per admission if pre-authorisation not obtained Medical technologists – Unlimited Mental health – Accommodation, theatre fees, medicine, hospital equipment, professional fees of GPs, Psychiatrists and Psychologists • Limited to R17 639 per family per year • Maximum of 3 days’ hospitalisation by GP • Limited to 1 individual psychologist consultation and 1 group psychologist consultation per day • Educational and industrial psychologists excluded • All limits are subject to PMBs Oncology (chemo and radiotherapy) – In and out of hospital • Includes medicine and materials • Limit of R317 522 per family per year • Sub-limit of R240 004 per family per year for biological and similar specialised medicines • Includes cost of pathology, related radiology benefit, medical technologists and oncology medicines • Subject to MPL • Erythropoietin included in blood transfusion benefit • Excludes new chemo-therapeutic 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 • Authorised erythropoietin included in blood transfusion benefit • Organ harvesting limited to South Africa, except in the case of corneal grafts • Sub-limit of R19 960 per beneficiary per year for corneal grafts (imported corneal grafts subject to managed care rules) 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, or/and all temporary or permanent devices used to assist with the guidance, alignment or delivery of internal prostheses and devices • Shared with medical and surgical appliances as well as external prostheses benefit of R40 010 per family per year • Scheme may obtain competitive quotes or arrange supply of prostheses • Bone cement paid from in-hospital benefit • 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) – 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 • Limited to R251 993 per beneficiary per year for chronic dialysis • Acute dialysis included in the in-hospital benefit • Includes cost of pathology, radiology, medical technologists and immuno-suppressants • Erythropoietin included in blood transfusion benefit Specialist services – 100% of Scheme Rate for non-network specialists • 130% of Scheme Rate for established network specialists • Consultations and visits • Unlimited • Reimbursement according to Scheme-approved tariff file 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
RUBY – Out-of-Hospital Benefits
Personal Medical Savings Account (PMSA) – Excludes PMB claims • 20% of annual gross contributions made by member during the financial year • Benefits pro-rated from join date
Allied health services – Includes chiropractors, dieticians, homeopaths, podiatrists, phytotherapists, social workers, orthoptists, acupuncturists, and Chinese medicine practitioners • Limited to PMSA and block benefit
Audiology, occupational therapy and speech therapy – Limited to PMSA and block benefit
SAPPHIRE
Block benefit (day-to-day benefit)–– Claims
In-Hospital Benefits
paid against this benefit once PMSA limit is reached • Limited to R1 671 per family per year • Benefit is pro-rated from join date
SAPPHIRE –– In-Hospital
In-Hospital
Prescribed
Circumcision – Global
SAPPHIRE minimum
fee of R1 Benefits
Benefits
421 per benefits (PMBs)
beneficiary, which –includes
R208 237 per family
all related costsper annum, subjectcare
of post-procedure to PMB legislation
within month of•procedure
Service provided
• Out ofbyhospital
DSP •only
PMBs override all benefit limitations
Contraceptives (oral,
Prescribed insertables,
Yearlybenefitshospital(PMBs) injectables
benefit (public and dermal)GEMS-approved
hospitals, –per Subject to PMSA 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 minimum minimum and benefitsequipment
hospital (PMBs) ––(includingR208
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of R208•237 per family per year •conscious
TTO limited to 7 days • No limit per maternity confinement
Dental
Yearly services
hospital (conservative
benefit (public and
hospitals,restorativeGEMS-approved dentistry including acute medicine) – Shared in-hospital dentistry limit R3 200 per beneficiary per year • No pre-authorisation ametal base partial General anaesthesia and sedation require pre-authorisation
Yearly
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• Excludes
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all implant-related
and registration – Subject
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000 for treatment
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beneficiary to yearly
per yearhospital limit and
• Fluoride registration
treatment excluded on Scheme’s
for beneficiaries Maternity older Programme
than 16 years • Co-payment of R1 000 per admission if pre-authorisation not obtained
Alcohol and Allied health services – Includes 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
Alcohol
Emergency and drug drug dependencies
assistance dependencies
(road and– air)
– Subject
Subject to
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– Subject PMBs, to use
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of legislation
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services –– Includes chiropractors, dieticians, homeopaths, podiatrists, phytotherapists, social workers, orthoptists, acupuncturists and Chinese medicine practitioners •• Limited to PMBs •• Subject to referral by network
network GP and services being related to admission diagnosis
General Practitioner (GP)
Alternatives services
Includes – Consultations,
chiropractors,
to hospitalisation dieticians, visits homeopaths,
(sub-acute and hospitals
all other services podiatrists,
and private phytotherapists,
• Limited to PMSA
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GP network extender Blood benefit
transfusion – For –beneficiaries
Includes costwith of chronic
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equivalents, on the
blood disease
products and management
transport programme • 1 additional consultation at network GP once PMSA and block benefit is exhausted
thereof
Alternatives
Alternatives to 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 823 823 perper family
family per per yearyear •• 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
HIV infection, AIDS Breast and reduction
related illness –blood, – Includes 1 consultation for diagnosis and initial counselling • Subject to PMBs and managed care • Pre-exposure prophylaxis included for high risk beneficiaries
No benefit
Blood transfusion – Includes cost of blood equivalents,
Blood transfusion – Includes cost of blood, blood equivalents, blood products and transport thereof blood products and transport thereof
Infertility – Subject to use of DSP
Breast reduction Dental
–– No services (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
benefit
Breast
Maternity reduction
(ante-related andNo post-natal
benefit
procedures, care) – 100% of
orthognathic Scheme
surgery andRate paid fromdentistry
specialised risk, if registered
• SubjectontoMaternity list of approved Programme services • Subject
and use to:ofMaternity
day theatresProgrammeand DSP protocols
hospitals and processes, Managed Care Protocols and PMBs OR 100% of Scheme Rate paid from PMSA, if not registered
Dental
Dental services (conservative,
services Programme
on the Maternity (conservative, restorative
restorative
• Subject to PMBs and
and specialised) • (Kindly––contact
specialised) Only
Only applicable
GEMS to obtain
applicable to
to beneficiaries
more detailwith
beneficiaries on severe
with trauma,
trauma, impacted
the consultations
severe and benefits
impacted third
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funded
under the age
age of
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years
years ••Maternity
Subject to
to yearly
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Subject Programme) 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
related procedures, Emergency
orthognathic services
surgery (casualty
and specialised department)dentistry – •• Subject to list
related
Medical procedures,
and surgical orthognathic
appliances surgeryandand specialised
prostheses dentistryhearing
– Includes Subject list of
of approved
aids,towheelchairs,approved services
services
mobility scooters,
and
and use use
oxygen
of
of day
day theatres and
and DSP
theatresnebulisers,
cylinders, DSP hospitals
hospitals
glucometers, colostomy kits, diabetic equipment, foot orthotics and external prostheses • In and out of hospital • Shared limit with in-hospital internal
Emergency
prostheses ofservices
Emergency R40GP
services 010services
per family– department)
(casualty
(casualty
Consultations
department)
per year • Sub-limit ––and visitsof R15 • Subject
611 per to yearly
family perhospital
year forlimit
medical • Reimbursement
and surgical appliances according• Sharedto Scheme-approved tariff file for
sub-limit with in-hospital maternityofconfinement,
prosthetics R4 394 for foot applicable
orthoticstoand both caesarianwith
prosthetics anda non-caesarian
sub-limit of R1 255 delivery
for orthotic shoes, foot inserts and levelers per beneficiary
GPper year
services • R500– Maternity
for crutches
Consultations (hospital,
per
and beneficiary
visits •home per
Subject birth year
to and
•
yearly R5 accredited
500
hospital for limit birthing
wheelchairs
• unit
per
Reimbursement (public
beneficiary hospitals
per
according year to and
• R8 designated
000
Scheme-approved per private
hearing aid
tariff hospitals))
per
file for beneficiary
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Subjectyear
confinement, •
to Bilateral
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Maternity
both 36
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Programme
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caesarian
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opinion • Hospitalisation the chronic
designated private hospitals for
GP services
medicine benefit– Consultations
•post-discharge
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• Subjectfortoquotes
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newborns hospital
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limited limit
to 6• weeks
orthotics Reimbursement
and prosthetics
• Includessubjectaccording
midwife to Scheme-approved
to services
formulary Subject to tariff
••Co-payment PMBs
of R1file000for maternity
per admission confinement, applicable not
if pre-authorisation to both caesarian and non-caesarian delivery
obtained
Maternity
Maternity (hospital,
(hospital, home birth
hometechnologists and
and accredited
birthassessments, accredited birthing
birthing unit
unit (public
(public hospitals
hospitals and
and designated
designated private
private hospitals))
hospitals))–––Consultations,
Subject
Subject to to registration
registration on
on the the Maternity
Maternityand/or Programme
Programme •• Elective
Elective caesarian
caesarian may
may and be
be subject
subject to
to second
second opinion
opinionto••PMSAHospitalisation
Hospitalisation in
in designated
designated private
private hospitals for
hospitals and
for
Mental health (Consultations,
Medical –limited
Includes treatment and/or counselling PMBsby • GP, Psychiatrist and Psychologist) assessments, treatments counselling by GPs, psychiatrists psychologists • Limited and 1 individual psychologist consultation
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 pre-authorisation
Co-payment
Co-payment of
of R1
R1 000
000 per
per admission
admission ifif pre-authorisation
pre-authorisation not
not obtained
obtained
1 group psychologist consultation per day • Educational and industrial psychologists excluded • If offered as alternative to hospitalisation, then hospital benefits will apply • Limited to PMBs
Medical technologists Mental– health – Accommodation, theatre fees, medicine, to hospital 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
Medical technologists
Optical services – Includes
Includes materials
(eye examinations, materialsframes,
•• Limited
lenses,
Limited to PMBs
PMBs •• Subject
to contact lenses to
Subject event
event pre-authorisation
(permanent or disposable) and acute medicine) – Subject to optical managed care programme • Limited to PMSA and block benefit • Limited to 1 eye examination per beneficiary per year • Benefit not pro-rated
pre-authorisation
Mental
• Framehealth
Mental sub-limit
health –– Accommodation,
of R1 289 per beneficiary
Accommodation, theatre
theatre • Post-cataract
fees,
fees, medicine,
medicine, hospital surgery,
hospital optical PMB
equipment,
equipment, benefit limited
professional
professional fees toof
fees of the cost of
General
General a bifocal lens
Practitioners,
Practitioners, not more than
Psychiatrists
Psychiatrists andR1 061 for both••lens
Psychologists Subjectand to frame, with a sub-limit
pre-authorisation andofmanaged
and R210 for care the frame
protocols• Either spectacles and
•• Educational or contact
industrial lenses will be funded
psychologists in a benefit
excluded year,to
•• Limited tonot both
PMBs
Oncology (chemo and radiotherapy)
• Includes tinted lenses up to 35% tint for albinism and proven photophobia, subject to pre-authorisation – In and out of hospital • Includes medicine and
• Excludes materials
variable•tint Subject to and
and photochromic
Psychologists
clinical guidelines Subject to pre-authorisation managed care protocols Educational and industrial
lenses used in public facilities and MPL • Excludes new chemotherapeutic medicines that have not demonstrated a survival advantage of more than
psychologists excluded Limited PMBs
3 months in advanced and metastatic solid organ malignant tumours unless pre-authorised
Orthopedic
Oncology
Oncology Disease
(chemo
(chemo and
and Management
radiotherapy)
radiotherapy) Programme
–– In
In andand –out out– Negotiated
of
of hospital
hospital rate • Subjectmedicine
•• Includes
Includes to managed
medicine andcare
and protocols
materials
materials and processes
•• Subject
Subject to
to clinical
clinical guidelines used in
in public facilities and
and MPLMPL •• Excludes
Excludes new new chemotherapeutic
chemotherapeutic medicines medicines that that havehave notnot demonstrated
demonstrated aa survival survival advantage
advantage of of more
more than
33Pathology
months Organ and tissue transplants Subject to pre-authorisation and clinical guidelines used in public facilitiesguidelines
• Subjectused to PMBs public
• Includesfacilitiesmaterials than
months in in –advanced
Limited toand
advanced and PMSAmetastatic
metastatic
and block solid
solid organ
organ•malignant
benefit malignant tumours
tumours unless
Includes liquid-based unless
cytologypre-authorised
pre-authorised
pap smear
Organ and Pathology – Subject to yearly hospital limit and clinical guidelines used in public facilities • Subject to PMBs • Includes materials
and tissue
Physiotherapy
Organ tissue – transplants
transplants
Limited to PMSA –– Subject
and block
Subject to
to pre-authorisation
benefit – Post-hip,
pre-authorisation andknee clinical and shoulderused
guidelines replacement or revision
in public facilities surgery
• Subject physiotherapy
to PMBs • Includes• materials10 post-surgery physiotherapy visits (shared with in-hospital visits) up to a limit of R5 021 per beneficiary per event used within 60 days of surgery
Pathology 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
Pathology –– Subject Subject to to yearly
yearly hospital
hospital limitlimit
Prescribed medicine
Physiotherapy
Physiotherapy –– Prostheses
Post-hip, and injection
knee – Covers
and material
prostheses
shoulder –replacement
and surgically
Prescribed implantedsurgery
andoradministered
or revision
internal devices, including
by a professional
physiotherapy all post-surgery
legally• entitled
• –10
temporary
to do soprostheses
•physiotherapy
Subject to andMPL allvisits
accompanying
MEL withtemporary
and (shared Acute medical
–out-of-hospital or permanent
conditions
visits)
visits) up
devices
to used
•limit
to aa394
Subject
of R5totoassist
PMSA
021 with
per andthe guidance,
a limit
per beneficiary
of R527
per alignmentusedand
per family
event perdelivery
within year
60 for of
60R1days
internal
homeopathic
of surgery prostheses
medicine••Subject Subjecttotothe yearly hospital limit and
formulary
• 30% co-payment aPost-hip,
sub-limit knee
of R23
on out-of-formulary and 790shoulder
per family
medicine replacement
• per
Includesyear prescribed
• Bone revision
cement surgery
maternitypaid vitamin
from physiotherapy
in-hospital
supplements benefits10Chronic
post-surgery
• Shared physiotherapy
sub-limits
medical •visits
with out-of-hospital
conditions (shared
Subject withapplication
prosthetics
to prior out-of-hospital
and appliances
and approval upand
of R4 limitof
use forofchronic
R5 orthotics
foot 021 medicine beneficiary
andpharmacy perDSP
prosthetics event
with aused within
sub-limit
• Unlimited forofCDL days
255of
and forsurgery
DTP orthotic shoes, foot
PMB conditions inserts
• All otherand levelers per beneficiary
non-PMB
Prostheses
Prostheses
conditions subject–– Covers
Covers per prostheses
year.
to PMSA Foot
prostheses• 30% and
orthotics
and surgically
co-payment
surgically implanted
and prosthetics
on internal
internaltodevices,
subject
out-of-formulary
implanted formulary
medicine
devices, including
• R500
and
including all
allfortemporary
voluntary crutches
use of non-DSP
temporary prostheses
per beneficiary
prostheses –and
and all
all accompanying
per
PrescribedaccompanyingR5 500temporary
year •medicine for
from
temporary or
or permanent
wheelchairs
hospital per beneficiary
stay
permanent (TTO) devices
• Subject
devices used
per
used toto
year assist
•assist
toPMSA R4 •500 with
TTOper
with the guidance,
hearing
limited
the to 7aid
guidance, daysalignment
perand and
andbedelivery
beneficiary
alignment must per yearof
related
delivery ofto•internal
Subjectprostheses
admission
internal internal ••and
todiagnosis
prostheses Subject
and external to
to the
procedure
Subject •yearly
devices
the hospital
being
Payable
yearly limit
related
from
hospital and
risktoonce
limit admission diagnosis
and
aaPMSA
sub-limit of
of R23
is depleted
sub-limit R23 and 790
790 per
per family
procedure
– Self-medicine family •per per year
year ••toSubject
Subject
(OTC) Bone
PMBs
Bone cement paid
paid from
to formulary
cement • Schedule
from in-hospital
in-hospital 0, 1benefits •• Shared
and 2 medicine
benefits Sharedcovered sub-limits
sub-limits with
with out-of-hospital
• Subject to PMSA and limited
out-of-hospital prosthetics
prosthetics to R178and
andper appliances
beneficiary
appliances of
of R4R4per394eventfor
394 for foot
foot orthotics
orthotics and and prosthetics
prosthetics with with aa sub-limit
sub-limit of of R1
R1 255
255 for for orthotic
orthotic shoes,
shoes, foot foot inserts
inserts and and levelers
levelers per
per beneficiary
beneficiary
per
per year.
year. Foot
Foot orthotics
orthotics and
and prosthetics
prosthetics subject to to formulary • R500
R500 for crutches
crutches per beneficiary per year •• R5
R5 500500 for wheelchairs
wheelchairs•per beneficiary per
per year • R4R4 500 per
per hearing aid
aid per beneficiary
beneficiary per year •• Subject to
to internal and
and external devices being
being related
related to admission diagnosis
Preventative
and procedure care
•• Subject services
Radiology to – Payablesubject
(advanced)
PMBs – Subject
from risk formulary
to list of•Influenza
• Includes approved forvaccination,
services perHPVbeneficiary
vaccination perandyearPneumococcal for vaccination per beneficiary
Influenza vaccination yearand• HPV 500
vaccinationhearing(for female per beneficiaries) per year to
limited Subject
1 per year internal
unless indicated external devices
otherwise • Pneumococcal tovaccination
admission oncediagnosis
every
and procedure Subject to PMBs
5 years for beneficiaries at risk • Subject to managed care protocols and processes • Includes screening services provided by network pharmacies
Radiology Radiology
(advanced) –– Subject (basic) to – Subject to yearly hospital limit • Includes 2 x 2D ultrasound scans per pregnancy
Radiology
Screening(advanced)
services – Serum Subject to list
list of
cholesterol, of approved
approved
bone density
services
services
scan, pap smear (including liquid-based cytology), prostate specific antigen, glaucoma screening, serum glucose, occult blood test, Thyrotropin for neonatal hypothyroidism, mammogram and other screening according to evidence-based
Radiology (basic) Renal dialysis – In hospitalscreening • Includes testmaterials and related tariffpathology tests • Subject to clinical
servicesguidelines
provided inused in public facilities
Radiology (basic)•––Neonatal
standard practice Subject to
to yearly
yearly hospital
Subject hypothyroidism hospital limit limit •• Includes
IncludesTSH22(Thyrotropin)
xx 2D 2D ultrasound
ultrasound scans
scans•per
4507 per pregnancy
Includes
pregnancyscreening network pharmacies
Renal dialysis
Radiology Specialist
–– In
(advanced) services
– Shared – Consultations and visits • 100% of Scheme Rate for non-network providers • 130% of Scheme Rate for established network specialists
coronary• angiography,
Subject to yearly hospital
scans,limitPET •scans,
Reimbursement according to Scheme-approved tariff file
Renal dialysis In hospital
hospital •• Includes
Includes materials
materials and
with in-hospital advanced
and related pathology
relatedradiology
pathology tests
limit
tests •• Subject
of R21 166 per
Subject to clinical
to family
clinicalper guidelines
year • Specific
guidelines used
used in public
public facilities
inauthorisation required for angiography,
facilities CT scans, MDCT, MUGA MRI scans and radio-isotope studies
Radiologyservices
Specialist Surgical
(basic) –– X-rays procedures
and softand (including
tissue ultrasound 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
Specialist services surgery
Consultations
Consultations and visits
visits 100%scans
•• 100% of
of Scheme• 2 x Rate
Scheme 2D
Rateultrasound
for
for non-networkscans provided
non-network providersfor••by
providers 130%
130%maternity of
of SchemebenefitRate
Scheme • Subject
Rate for to PMSA network
for established
established network specialists
specialists •• Subject Subject to to yearly
yearly hospital
hospital limit limit •• Reimbursement
Reimbursement according according to to Scheme-approved
Scheme-approved tariff tariff file
file
Renal dialysis
Surgical
Surgical procedures
procedures – Out(including
of hospital •maxillo-facial
(including Includes materials
maxillo-facial surgery)
surgery) –– Subject
and related Subject pathology to
to yearly
yearlytests • Subject
hospital
hospital limitto••pre-authorisation,
limit Subject
Subject to to case managed care•• protocols
case management
management Maxillo-facial
Maxillo-facial and processes
surgery
surgery subject • Limited
subject to to PMBs
to yearly
yearly • Subject
sub-limit
sub-limit of
of R20 to use
R20 823ofper
823 pera Renal
familyDialysis
family •• Excludes Network
Excludes DSP • If a non-network
osseo-integrated
osseo-integrated implants,
implants, all provider is voluntarily
all implant-related
implant-related used, a co-payment
procedures
procedures and of 15%
and orthognathic
orthognathic
will be applied per event in accordance with network rules
surgery
surgery
Specialist services – Consultations, visits and all other services • 100% of Scheme Rate for non-network providers • 130% of Scheme Rate for network specialists • Specialist consultations subject to referral by GP • Limited to PMSA and block benefit • Benefit is pro-rated from join date
• 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
