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Healthcare programmes

Prescribed minimum benefits

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:

  • State hospitals: The State is GEMS's DSP for the treatment of in-hospital PMBs. 
  • Chronic medicine DSPs: Members should use the chronic medicine Courier Pharmacy (Medipost) and contracted pharmacies in the chronic medicine Pharmacy Network to obtain all chronic medicine (including medicine for HIV). If they use another pharmacy they may have to make a co-payment out of their own pocket. Members are given an option to choose either the Courier Pharmacy or any network Pharmacy that is within 10 kilometres of their workplace or home as their chronic medicine DSP. Members are then required to remain with the pharmacy they have chosen for a period of six months, which is in line with the six-month script cycle.

Please note: 

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: 

  • The service was not available from the DSP or could not be provided without unreasonable delay; 
  • Immediate (emergency) medical or surgical treatment for a PMB condition was required under circumstances or at locations that reasonably precluded the beneficiary from obtaining such treatment from a designated service provider; or 
  • The DSP was not within reasonable proximity to the beneficiary's ordinary place of business or personal residence. 
  • Except in the case of an emergency medical condition, pre-authorisation must be obtained prior to the involuntary use of a non-DSP. In the case of an emergency hospital admission, a pre-authorisation must be obtained within one working day after the admission, after which a co-payment of R1 000 per admission shall apply. In order 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:
    • The service was not available from the DSP or could not be provided without unreasonable delay;
    • Immediate (emergency) medical or surgical treatment for a PMB condition was required under circumstances or at locations that reasonably precluded the beneficiary from obtaining such treatment from a designated service provider; or
    • The DSP was not within reasonable proximity to the beneficiary's ordinary place of business or personal residence. Except in the case of an emergency medical condition, pre-authorisation must be obtained prior to the involuntary use of a non-DSP. In the case of an emergency hospital admission, a pre-authorisation must be obtained within one working day after the admission, after which a co-payment of R 1000 per admission shall apply.

 

When is it an Emergency?

  • There is a real risk of death or loss of limb; or
  • The delay in treatment at the DSP places the beneficiary's life at risk.

Will GEMS transfer me to a DSP after an emergency admission?

  • GEMS will transfer beneficiaries to a designated service provider as soon as it is clinically safe to do so.
  • If a beneficiary chooses not to move, the implication is that the Scheme will only fund the remaining treatment at 100% of the GEMS Scheme rate. In other words, claims for the non-emergency portion of treatment will be paid as with any other claims where the beneficiary voluntarily used a non-DSP.

To what extent are the prescribed minimum benefits restricted?

  • The costs associated with the diagnosis, treatment, and care of the PMBs will be funded in full provided the services have been rendered by the DSP, managed healthcare protocols have been adhered to and clinical criteria have been met.
  • In instances where services are voluntarily obtained from a non-DSP, co-payments or other penalties may apply. If a non-DSP is used, except for medicine, the benefits payable by GEMS are limited to 100% of the GEMS Scheme rate. A 30% co-payment will be levied if medicine is obtained from a non-DSP.
  • Short-falls and co-payments arising from failure to use a DSP or adhere to the managed healthcare protocols may not be funded from a member's medical savings account.

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:

  • Hospitalisation in private hospitals (call 0860 00 4367 and select Hospital and Advanced Radiology Pre-Authorisations);
  • Chronic medicine (call 0860 00 4367 and select Chronic Medicine);
  • Oncology (cancer) treatment (call 0860 00 4367 and select Oncology Programme);
  • HIV management (call 0860 436 736 to register on the HIV/AIDS Disease Management Programme);
  • Renal dialysis (call 0860 00 4367 and select Hospital and Advanced Radiology Pre-Authorisations); or
  • Organ transplant (call 0860 00 4367 and select Hospital and Advanced Radiology Pre-Authorisations).

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:

  • Wishes to motivate for an authorisation since they are involuntarily making use of a non-DSP and their normal scheme benefits have been exhausted;
  • Wishes to appeal/provide motivation for services that are in excess of those provided within the funding guidelines and normal scheme benefits have been exhausted; or
  • Has a rare condition that is not covered by an existing funding guideline and normal Scheme benefits have been exhausted.

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

  • If the application is for additional PMB benefits (i.e. additional services like extra consultations, pathology or radiology tests), sections A, B, D and E need to be completed by yourself and the treating doctor. Section C should only be completed if you are also requesting that the non-DSP payment rules be overridden (i.e. providing motivation regarding the involuntary use of a non-DSP).
  • If the application is limited to a request to override the non-DSP payment rules (i.e. providing motivation regarding the involuntary use of a non-DSP), sections A, C and D are compulsory.
  • It is only necessary to have your doctor complete sections B, and E if you motivating that the treatment required is not available from the DSP (in which case we require treatment details). Once the application form has been completed and signed, the form must be faxed to 0861 00 4367. The application/motivation will be reviewed and the decision will be communicated to the member and the healthcare practitioner.

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.

Prescribed minimum benefits pre-authorisation form

 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.

  • Funding Guidelines (Protocols) have been developed for most PMB conditions with the exception of some rare conditions which are managed on a case-by-case basis.
  • The funding guidelines include criteria for validating that the beneficiary has a PMB condition as well as the reasonable PMB treatment that should be provided for a particular condition.
  • Validation of a particular PMB condition may include determining whether the beneficiary is registered with the condition on an appropriate managed healthcare programme (e.g. chronic medicine, HIV or oncology management) or requesting additional clinical information.
The funding guidelines also define reasonable treatment for a particular condition. This may include defining the number of consultations available from a GP or relevant Specialist, diagnostic tests, and other services that should be funded for a disease