Frequently asked questions about Prescribed Minimum Benefits

What are the prescribed minimum benefits (PMBs)?

These are the minimum benefits, in respect of relevant health services, that a scheme must provide to members and is prescribed by the regulations under the Medical Schemes Act.  The scheme can, however, apply clinical criteria and managed healthcare protocols to the PMBs and stipulate that members make use of a designated service provider for the provision of PMB services.

What conditions should be treated as a PMB?

The specific conditions are defined within the diagnostic treatment pairs (DTPs) and on the chronic disease list (CDL). In addition, any emergency medical condition should be considered a PMB.

What are the Diagnosis and Treatment Pairs?

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?

From 2004 the PMBs were extended to cover the diagnosis, medical management and medication of a specified list of chronic conditions known as the Chronic Disease List. There are 25 chronic conditions covered by the CDL.

The Council for Medical Schemes chose these conditions based on their frequency, severity and response to treatment and published treatment algorithms for schemes to use as a guideline on how to cover medicine for the 25 conditions.

In addition to the 25 diseases on the CDL, there are some chronic conditions in the 270 DTPs that require chronic medication.
A list of these conditions can be obtained from the Council for Medical Schemes website: www.medicalschemes.com

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. GEMS have selected the State as their DSP. Medipost (pharmacy) has also been selected as a DSP for the provision of out-of-hospital medication. 

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. 

What if I cannot make use of the scheme's DSP?

In order to determine the reimbursement that should be made for PMB treatment provided, the scheme will determine whether the beneficiary voluntarily or involuntary made use of the non-DSP. Involuntary use means that:

1.    The service was not available from the DSP or could not be provided without unreasonable delay;
2.    Immediate (emergency) medical or surgical treatment for a PMB condition was required under circumstances or at locations which reasonably precluded the beneficiary from obtaining such treatment from a designated service provider; or
3.    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, a pre-authorisation must be obtained one working day after the provision of care or one working day after the member is capable of obtaining a pre-authorisation.  If a pre-authorisation is not obtained, services will only be paid at the SCHEME RATE.  Where medication is provided (out-of-hospital), a 30% co-payment will be levied.

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 you 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 SCHEME RATE.  In other words, claims for the non-emergency portion of treatment will be paid as with any other claim where the beneficiary voluntarily made use of a non-DSP.

How do I obtain a pre-authorisation to make use of a non-DSP?

Please refer to the section below that describes how a beneficiary obtains a PMB pre-authorisation.

Please note: Where services from a DSP are not available the member should call the GEMS call centre at 0860 00 4367 to contact the relevant area in order to ascertain an alternative place of treatment.

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 (100% reimbursement) provided the services have been rendered by the DSP (State or Medipost, where applicable), 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, with the exception of medication, the benefits payable by GEMS is limited to the SCHEME RATE.  A 30% co-payment will be levied if medication 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?

NO - a specific PMB pre-authorisation is not required. 
The following pre-authorisation processes are in place and are a scheme requirement, regardless of the PMB status:

• Hospitalisation (call 0860 004 367 and select Hospital and Advanced Radiology Pre-Authorisations),
• Chronic Medicine (call 0860 004 367 and select Chronic Medication),
• Oncology (cancer) Treatment (call 0860 004 367 and select Oncology Programme),
• HIV Management (contact AfA on 0860 100 646),
• Renal Dialysis (call 0860 004 367 and select Hospital and Advanced Radiology Pre-Authorisations), or
• Organ Transplant (call 0860 004 367 and select Hospital and Advanced Radiology Pre-Authorisations).

Where applicable, the standard pre-authorisation application will be flagged as a PMB at the time that it is pre-authorised and treatment will be paid accordingly.  
 
Treatment that falls outside of the areas listed above (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.  The only time a pre-authorisation is required for an ambulatory PMB is if the beneficiary:

1. Wishes to motivate for an authorisation since they are involuntarily making use of a non-DSP and their normal scheme benefits have been exhausted; or
2. 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
3. Has a rare condition that is not covered by an existing funding guideline and normal scheme benefits have been exhausted.

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 possibly 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 of the scheme or the organisations responsible for providing administration and/or managed healthcare services to the scheme.

What is a Funding Guideline (Protocol)?

Your scheme carefully manages the PMB benefit to ensure that beneficiaries are provided with good quality, appropriate health care 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, diagnostic tests and other services, per healthcare practitioner group (discipline) that should be funded for a disease. 

How do I appeal a funding decision?

To appeal a funding decision, request a clinical motivation from your healthcare provider and call the GEMS call centre on 0860 00 4367 to direct your appeal to the appropriate unit.

Please ensure that this clinical appeals process is followed in order to ensure that the Scheme deals with your concerns appropriately.

The clinical appeals process involves the following steps:

1. Clinical evaluation of the initial decision by the medical advisor
2. Clinical evaluation by a committee/forum (includes external relevant experts)
3. Clinical appeal to the ex gratia committee
4. Written appeal to the Principal Officer
5. The member has the option of appeal to
a. the GEMS dispute resolution committee
b. Council for Medical Schemes (CMS)
The decision at each point of appeal is communicated to the member and provider.

How do I apply for a PMB pre-authorisation?

Please note - a pre-authorisation is not required unless the beneficiary:

1. Wishes to motivate for an authorisation since they are involuntarily making use of a non-DSP and normal scheme benefits have been exhausted; or
2. 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
3. Has a rare condition that is not covered by an existing funding guideline and normal scheme benefits have been exhausted.
If a PMB pre-authorisation is required, a PMB application form must be completed and submitted to the PMB case managers for review. The application form is available from the GEMS call centre (0860 00 4367) or can be downloaded from the Forms section. 

If the application is for additional PMB benefits (i.e. additional services like extra consultations, pathology or radiology tests), sections A, B and C need to be completed by yourself and the treating doctor.  Section D should only be completed if you are also requesting that the non-DSP payment rules be overridden (i.e. providing motivation w.r.t 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 w.r.t. the involuntary use of a non-DSP), sections A and D are compulsory. It is only necessary to have your doctor complete sections B and C if you are motivating that the treatment required is not available from the DSP (in which case we require treatment details) or completion of these sections will add value to the motivation.

Once the application form has been completed and signed, the form must be faxed to 0861 004 367. 
The application/motivation will be reviewed and the decision will be communicated to the member and the healthcare practitioner.