The Scheme rate and your right to negotiate

Before July 2010, all providers were given a reference guide in regards to what they may charge for procedures and visits. This was referred to as the National Health Reference Price List and was issued by the Council for Medical Schemes on behalf of the Department of Health. This was discontinued in July 2010, and since then what is called the Reference Price List has been used. The GEMS scheme rate is calculated on RPL +6%.

What do providers charge?

Not all providers have historically charged NHRPL /RPL tariffs, but it was used as a guideline for practitioners and medical aid schemes to calculate tariff and design benefit structures. In the same way practitioners were not bound by NHRPL, medical aid schemes were free to calculate their own scheme rates. Historically, there was another list of published rates which HPCSA (Health Professions' Council of South Africa) published. This was referred to as ethical medical tariffs. The HPCSA announced in November 2008 that it was doing away with these ethical tariffs and, in essence, scrapping their publication.

What if my provider charges in excess of the GEMS scheme rate, and I have funds available in my day-to-day plan or Block benefit?

The availability of funds in your savings portion does not mean GEMS will reimburse above the scheme rate. All accounts will be reimbursed at scheme rate.

How will I know what a provider charges and if GEMS will pay for it?

All providers are by law complied to give medical aid members a quotation of services and explain what will not be covered by the medical aid. They display this usually at the reception, and state that they charge above medical aid rates. A member may of course negotiate with the provider to charge scheme rates. This is your right, as it is your right to obtain services from a different provider.

Where a provider charges more than the scheme rate, you as the member will be liable for all outstanding fees not covered by GEMS.

You may verify what the scheme rate is by accessing the GEMS website or by contacting us at 0860 00 4367.

What providers will charge above scheme rate?

Providers on the Friends of GEMS provider network will charge the scheme rate. This means that where you see the GEMS network sticker displayed, you can be assured that you will have no co-payments as long as you have benefits or have been registered on the PMB programme.

Specialists and anaesthetists, and some physiotherapists may charge above scheme rate. It is your right to enquire what they charge, and you may negotiate that they charge you the Scheme rate.

Remember that state hospitals are the designated service provider for all options for PMB diagnosis. Should you require a procedure for a PMB diagnosis, and you want to be assured of no co-payment, it is recommended you make use of a state hospital closest to you. When you contact the pre-authorisation call centre to obtain your authorisation, they will advise you of the scheme rate and also of your closest state hospital.