What are non-covered items?

When a member goes to hospital, there will be certain items that are not covered by the Scheme in the interests of keeping healthcare as affordable as possible.

The list of items that will not be covered is updated frequently but usually involves items that have not yet been proven to be effective over a long time or procedures where there are alternative treatments available at much lower cost with no negative impact to the patient.

All hospitals are informed on a quarterly basis, and you will be advised in writing of applicable non-covered items during your authorisation procedure. It is, however, very difficult to determine exactly what products/procedures will not be covered unless you inform the scheme at the time of authorisation.  This should be a discussion between you and your doctor before your admission or surgery. This will include certain laparoscopic procedures (where a small camera is inserted through an incision and a procedure is performed through this). On average these procedures are R7 000 - R10 000 more expensive than the open surgical procedure. These procedures will only be covered if the additional cost outweighs the advantage of the procedure over the open surgery.  An example of this would be a Laparoscopic Hysterectomy, where the woman's uterus (womb) is removed through a few smaller incisions. Although the procedure is usually associated with shorter hospital stays and shorter recovery time, it requires a highly skilled surgeon with many hours of expertise with this specific procedure. In many cases the complications of this procedure outweigh the benefit. This may include the perforation of blood vessels which could lead to severe bleeding and infection. These procedures are planned and often discussed with patients before the procedure. Should you and your surgeon choose to go ahead with the laparoscopic procedure, you will be liable for the additional costs of not only the equipment used but also the additional costs that the provider may charge.

Another example of an item that will not be reimbursed relates to any unregistered drug. All medication administered in South Africa have to be registered with the Medicine Control Council of South Africa (MCC). This protects all patients from receiving drugs that have not been deemed safe or have not been proven to have long term benefits. GEMS will not pay for these drugs, as it would be unethical and illegal.

As a patient, you are entitled to discuss all treatment options with your doctor, and together decide on what the best option would be for you or your family. Once you have decided on the best option, discuss the options with the staff in the pre-authorisation department.  They would advise you whether this will be covered by the scheme. A medical advisor for the scheme will discuss any alternative treatment options with your treating provider should the scheme not cover your procedure.