Prescribed Minimum Benefits (PMBs) are the basic benefits that GEMS provides for certain medical conditions, such as asthma and hypertension.
What conditions should be treated as a Prescribed minimum benefits?
The specific conditions are defined within the diagnostic treatment pairs and on the chronic disease list. In addition, any emergency medical condition should be considered a Prescribed Minimum Benefits.
About Prescribed Minimum Benefits
Qualifying for PMBs is not only based on the condition or diagnosis but also on the treatment provided by the healthcare provider. The treatment must be in line with what is prescribed in the Medical Schemes Act Regulations. If the treatment provided is not what is written in the Regulations, it cannot be claimed as a Prescribed Minimum Benefits.
Prescribed Minimum Benefits will be covered from your available benefits and when your benefits are depleted, the Scheme will continue to pay for PMBs above the benefits.
What are the Diagnosis and Treatment Pairs?
The Diagnosis and Treatment Pairs (DTPs) is a list of the 270 conditions linked to specified treatment that must be funded by schemes for these conditions. The treatment and care of some of the conditions included in the DTPs may include chronic medicine (see the Chronic Disease List for more information). A list of these conditions can be obtained from the CMS’ website: www.medicalschemes.com. When determining whether to fund treatment for these conditions as PMBs, the scheme, and its managed healthcare organisation must base their decisions on the provisions of the law, the level of healthcare available in the public sector as well as the treatment and care that is best suited for the condition, while taking affordability into account.
The Diagnosis and Treatment Pairs (DTPs) is a list of the 270 PMBs linked to the broad treatment that should be provided for these conditions. When determining the specific treatment and care of these conditions as a PMB, the Scheme and its managed care provider should base their decisions on the level of healthcare that has proven to work best while taking affordability, and what is accessible in the public sector into account.
The treatment and care of some of the conditions included in the DTP may include chronic medicine (see Chronic Disease List for more information).
What is the Chronic Disease List?
There are 26 chronic conditions known as the Chronic Disease List (CDL). A list of these conditions can be obtained from the CMS’ website: www.medicalschemes.com. The CMS chose these conditions based on their frequency, severity and response to treatment, and published treatment algorithms (pathways) for schemes to use as a guideline on how to cover medicine for the 26 conditions. In addition to the 26 conditions on the CDL, HIV, and other conditions in the 270 DTPs that require chronic medication.
What is a designated service provider (DSP)?
A DSP is a healthcare provider or group of providers who have been selected by the Scheme to deliver to its members the diagnosis, treatment, and care in respect of one or more prescribed minimum benefit conditions. For the purposes of claims adjudication of PMB claims, GEMS has selected the State as its DSP for in-hospital services. If you choose to use a healthcare provider other than the DSP for the treatment of a PMB, the scheme may impose a co-payment or limit the rate at which the claim is reimbursed.
GEMS has selected the following DSPs for PMB care:
If you choose to use a healthcare provider other than the DSP for the in-hospital treatment of a PMB, the Scheme may impose a co-payment or limit the rate at which the claim is reimbursed. To determine the reimbursement that should be made for PMB treatment provided, the Scheme will determine whether the beneficiary voluntarily or involuntarily made use of the non-DSP. Involuntary use means that:
When is it an Emergency?
Will GEMS transfer me to a DSP after an emergency admission?
To what extent are the prescribed minimum benefits restricted?
Do I need a pre-authorisation for the Prescribed Minimum Benefits?
The following pre-authorisation processes are in place and are a Scheme requirement, regardless of the PMB status:
Treatment that falls outside of the areas listed above and is accessed in the out of hospital setting (e.g. doctor consultations, pathology or radiology tests) is referred to as an ambulatory PMB. A pre-authorisation is not required for these services as these claims will be automatically paid as a PMB, where appropriate, provided the correct ICD10 codes are used. The only time a pre-authorisation is required for an ambulatory PMB is if the beneficiary:
The aPMB application Form
The application form is available from the GEMS call centre (0860 00 4367) or can be downloaded from the GEMS website
What is an ICD10 code?
An ICD10 code is the diagnosis code that your healthcare practitioner includes on the claim. This is the only way for the Scheme to identify whether the claim is possible for a prescribed minimum benefit. Please also note that any diagnostic information provided on the claim will be kept confidential and will not be disclosed to anyone outside the Scheme or the organisations responsible for providing administration and/or managed healthcare services to the Scheme.
What is a Funding Guideline (Protocol)?
GEMS carefully manages the PMB benefit to ensure that beneficiaries are provided with good quality, appropriate healthcare that is cost-effective, affordable and sustainable. We use strict clinical guidelines and expert advice to make sure we are funding the most appropriate treatment.