Enrolment on GEMS is voluntary for public service employees who were appointed before 1 July 2006 and were principal members of open medical schemes in June 2006. Employees who were appointed with effect from 1 July 2006 as well as employees who were not principal members of open schemes in June 2006 will receive the employer subsidy on GEMS only.

An employee, who was a member of an open medical scheme in June 2006 and remained a member of an open scheme, may change to another open medical scheme with retention of the subsidy calculated as two-thirds of contributions limited to R1, 014 per month. This is subject thereto that there is no break in membership; in other words, the effective date of cover on the new scheme has to be directly after the date of termination on the old scheme.

New appointees with an appointment date of 1 July 2006 or later will only be subsidised on GEMS. They will not qualify for an employer subsidy if they join an open medical scheme.

Contract employees whose term of appointment is at least 6 months may join GEMS. Note that some contract employees are remunerated by means of all-inclusive remuneration packages, i.e. basic salary and a cash amount calculated as 37% of basic salary. PERSAL will not generate an employer subsidy when such a contract worker joins GEMS since the subsidy is already built into the remuneration package.

To ensure that you have all the information on the employer subsidy policy, you should read the Determination from the Minister for the Public Service and Administration on Medical Assistance for the Public Service as well the Circular from the Department of Public Service and Administration (the DPSA) under reference1/6/23/P dated 29 September 2006. The Determination and Circular are available in your HR office and can also be accessed on the DPSA website at http://www.dpsa.gov.za/.

GEMS became operational on 1 January 2006. Public service employees started enrolling on GEMS and the first claims from new members were paid in mid January 2006.

A dependant is:

• A member's spouse or partner who is not a member or registered dependant of another medical scheme;
• Ex-spouse, provided the member is still obliged to pay such ex-spouse's medical costs in terms of a divorce settlement agreement. Former in-laws, provided the member completes a motivation to keep them on and the motivation was approved by the Board of Trustees.
• A member's natural child, stepchild, adopted child and foster child of the member or of the member's spouse who is not a member or a registered dependent of a member on another medical scheme;
• A niece or nephew of the member or member's spouse under the age of 21 years, provided such person is financially dependent on the member;
• A sibling of a member or of the member's spouse provided that such a sibling is financially dependent on the member;
• A granchild, great-granchild and so forth of the member or of the member's spouse who is financially dependent on the member;
• Parents or parents in-law of a member, grandparents or grandparents-in-law of a member, sibling half-sibling or step-sibling of the member or of the member's spouse who is 21 years of age or older, a niece or nephew of the member or the member's spouse who is 21 years of age or older.
• An immediate family member in respect of whom the member is liable for family care and support.

To be registered as a child dependant, a dependant must be under the age of 21 and not be in receipt of an annual income of more than the maximum social pension. A dependant will also be considered as child dependant if he/she is:

• Younger than 28 years and is registered as a bona fide full-time student at a recognised tertiary institution and is not receiving an annual income of more than the Social Pension prescribed;
• Totally dependent on the member due to a physical or mental disability.

Members should note that for dependants to remain registered as child dependants, supporting documentation would be required by GEMS.

Yes, if the member has not had a break in membership and provided that the contributions are paid. The eldest dependant (if no spouse is registered as a dependant) will then be registered as the main member (adult dependant rates then apply). Normally the Estate is responsible for the monthly payments.

Yes, at least 1 (one) calendar month's written notice would be required. The member may terminate membership of the Scheme by giving one calendar month written notice, in line with the rules of the Scheme.

GEMS isF a legal entity separate from the employer and is governed by a Board of Trustees. In other words, the Board of Trustees determines the rules under which the Scheme operates, including benefits and contributions. The employer on the other hand determines the conditions of service of employees through negotiations with trade unions. In determining the conditions of service of public service employees, the employer may for example determine whether or not its employees are compelled to belong to one scheme or whether the employees have total freedom of choice of scheme. The employer also determines what level of subsidies will apply to different categories of employees or in general. Employers also play an important role in collecting contributions and ensure payment thereof to the scheme concerned.

No person may belong to more than one medical scheme at the same time. You may thus not be registered on two schemes. Even if your dependants are not covered on your current scheme, you may not join GEMS with the purpose to obtain cover only for your dependants. This constitutes dual membership.

The subsidy structure implemented on 1 July 2006 included a no worse off clause that allows members to receive the highest of the rand value of their subsidy on 30 June 2006, or the subsidy per the 75% calculation (subject to applicable limits). For example, a single employee with no beneficiaries who joins GEMS will receive a subsidy of 75% of the total contribution, limited to R670. If the employee received an employer subsidy of R710.00 on 30 June 2006, the employee will continue to receive the R710.00 employer subsidy, as it is greater than the 75% calculation.

Please note that the no worse off clause only applies to employees who received an employer subsidy on 30 June 2006. If no employer subsidy was received on 30 June 2006, the employee will only qualify for a subsidy equal to the 75% calculation. Another requirement for the no worse off clause is that there should be no break in membership when moving from your previous scheme to GEMS.

Please refer to the contribution calculator for further guidance on the calculation of your employer subsidy.

There are various reasons for suspending benefits, each with a different cause and impact on you.

Suspension due to incomplete registration:
This type of suspension is caused when insufficient supporting documentation was provided for the registration of the member or dependant. As the registration process is not complete, no benefits will be made available, nor will contributions be collected. Please provide GEMS with all the requested documents in order to complete the registration.

Suspension due to contribution or claims debt:
This type of suspension is caused by non-receipt of contributions or any member's share of claims. There are several reasons for not receiving a contribution, and it is in your interest to contact GEMS to resolve the matter. Please note that although benefits are not available during the period of suspension, contributions are still payable. You will not be entitled to a refund of contributions should benefits have been suspended, therefore always ensure that deductions are made from your monthly salary (or bank account, where applicable).

Chronic medication includes medicine for life threatening illnesses. Medicine used on an ongoing basis to treat disabling chronic illnesses that significantly affect productivity and quality of life.

Each member of your family who needs chronic medicine must complete a separate application form. You only need to complete this application form once, even if there are additions or changes in future.

Your treating doctor must examine you and complete the form. Sapphire and Beryl members must have their chronic forms completed by a GEMS Network Doctor.

Ensure that your application has been filled out in its entirety and signed by you and your doctor.

Fax the completed form and repeatable doctor's prescription to 0866 51 8009 for assessment. Keep a copy of your completed form for your own records.

Please also attach supporting tests, special investigations and/or motivations to prevent delays in the processing of your application.

A clinical team will review your details and where necessary will contact your doctor (telephonically or in writing) to select more appropriate and/or less costly medication.

You will receive a Medicine Access Card, listing the medicines which have been approved for payment from your Chronic Medication Benefit.

If the approved medication differs from the medication requested, a letter will be attached to your Medicine Access Card and a copy will also be sent to your prescribing doctor.

Your request will take approximately 5 working days to process. If required, you may follow up on the progress of your application by calling the GEMS Medicine Management Call Centre on 0860 00 4367.

The handwritten repeatable prescription from your doctor for the medicines listed on the Medicine Access Card, should be faxed to the Designated Service Provider (DSP) for chronic medicines at 0866 51 8009. Remember to include your medical scheme number and the correct contact and delivery address details on your prescription and all written correspondence submitted to the Chronic DSP.

The DSP will then contact you to make delivery arrangements and subsequently process and deliver your medication to the destination of your choice. The DSP will also ensure that you receive your chronic medication on a monthly basis, without you having to contact them. Should there be a change to your standard requirement, kindly provide the DSP with adequate notice (one week or more) prior to your next delivery date.

If you are on either the Ruby, Onyx or Emerald options and you choose to obtain your approved chronic medication from a supplier other than the GEMS Chronic DSP, you will be liable for a 30% co-payment, which must be paid directly to the pharmacy or dispensing doctor.

If you are on the Sapphire or Beryl options and you choose to obtain your chronic medication from a supplier other than the GEMS Chronic DSP, your medication will not be paid for by the Scheme.

Please note that the duration of authorisation varies from medicine to medicine - some medicines may be authorised on an ongoing basis, whilst others may only be authorised for a limited period. The Medicine Access Card will indicate the duration for which the medicine has been approved. Prescriptions have to be renewed every 6 months.

You need to supply the Chronic DSP with a valid copy of your doctor's prescription before we can provide you with medication. This is a legal requirement.

A repeat prescription is valid for not more than the repeats specified and effective from the date written on the prescription. A prescription cannot be repeated for more than six months. The Chronic DSP will remind you (in writing, via SMS or telephonically) to provide a new prescription from your doctor one month before your last repeat is sent out. The Chronic DSP will not send you further medication if your prescription has expired and you have not submitted a new one.

GEMS will pay for chronic medicines prescribed according to the medicine formularies applicable to your option subject to the Scheme rules.

The medicine formularies are lists of cost-effective medicines that guide the doctor in the treatment of specific medical conditions. Medicine formularies are continuously checked and updated by medical experts to ensure that they are consistent with the latest treatment guidelines.

In addition, only diseases listed in the Chronic Disease List (CDL), plus the conditions listed in the Additional Chronic Disease List (ACDL) per option, qualify for chronic medicine.

The Chronic Disease List (CDL) is a legislated list of 26 specific chronic conditions for which a minimum level of treatment is compulsory. When chronic limits are exhausted, the Scheme will continue paying for approved medicine for CDL conditions.

If your medicine request has been declined, a letter will be sent to you and a copy will be sent to your prescribing doctor. If further clinical information is required, your request will be reconsidered once all the relevant information has been received from your doctor. Your doctor may call 0860 100 608 for assistance. The GEMS Chronic DSP will only dispense approved chronic medication. The patient can advise the GEMS Chronic DSP if the rejected items need to be obtained from acute benefits.

If your chronic medication changes in any way, GEMS needs to be advised. The quickest way is for the prescribing doctor or dispensing pharmacist to contact the clinical staff on the Service Provider Line (0860 100 608). The change is processed within 5 days and if approved, a new, repeatable prescription must be faxed to the GEMS Chronic DSP who will then dispense the medicine within 48 hours of receipt of the prescription.

Remember that a repeatable doctor's prescription for the new medication must be faxed to the DSP at 0866 51 8009, as they may not dispense without a valid script.

An updated Medicine Access Card will be mailed to you for your records.

It is not necessary to request a new Medicine Access Card if the authorised product is replaced by a generic equivalent within the same MPL group.

The Medical Schemes Act specifies a list of Prescribed Minimum Benefits (PMBs) that have to be offered by all medical schemes for an extensive list of conditions. Within the list of PMBs, there are 26 chronic conditions which must be covered without any benefit limit by all schemes. The list, referred to as the Chronic Disease List (CDL), can be viewed on the Managed Healthcare page under Healthcare Providers. Medicine Formularies and specific treatment protocols are used by GEMS to treat CDL conditions, in accordance with legislation.

When chronic limits are exhausted the scheme will continue paying for approved medicine for CDL conditions.

Refer to the benefit schedule under Members > Communication Library or contact the Call Centre on 0860 00 4367.

The Hospital Management Programme ensures that you receive value for your benefits and appropriate, quality care while in hospital. Before you are admitted to hospital, or make an out-patient visit to a hospital, have a CT scan, MRI scan or Radio-Isotope study, you need to get a Pre-Authorisation number (PAR) from GEMS by contacting 0860 00 4367.

If a visit or admission to a hospital (out-patient or in-patient), or any scan is planned, please let us know 48 hours before the event. In the event of emergency treatment or admission to hospital over a weekend, public holiday or at night you MUST contact the Call Centre on the first working day after the incident. If you fail to get pre-authorisation for a planned event or authorisation on the first working day after an emergency event you will be liable to pay a R1 000 penalty.

• Your GEMS Membership number;
• The name and date of birth of the patient;
• The date of admission and the proposed date for the operation (if applicable);
• The name of the doctor and his/her telephone and practice numbers, if available;
• Name of the hospital with their telephone and practice numbers, if available;
• In the event of a CT scan, MRI procedure, or radiological procedure, the name of the radiological practice is also required;
• Ask your doctor for a full description of:
• the reason for admission to hospital or reason for scan;
• the associated medical diagnosis; and
• the planned procedure, as well as the tariff codes that the doctor intends to use.
• Only procedures which are covered in terms of the rules of your scheme will be covered.

• The unique PAR number;
• The approved length of stay and level of care in hospital; and
• The approved codes.

Please ensure that your doctor, the hospital case manager or a family member informs GEMS of the extended length of stay on 0860 00 4367. If there is a valid clinical reason for the stay, GEMS will approve the extra days.

From 2010 all hospital physiotherapy will require pre-authorisation. Certain hospital admissions or procedures will automatically generate a number of physiotherapy treatment sessions without pre-authorisation being required. The number of sessions should be indicated on your pre-authorisation confirmation letter. If more sessions are required or no physiotherapy treatment sessions are indicated on the letter, please ensure that your doctor, the treating physiotherapists or the hospital case manager calls GEMS for pre-authorisation on 0860 00 4367. If there is a valid clinical reason for the required physiotherapy treatment, GEMS will approve the treatment.

No, pre-authorisation is only required for physiotherapy while you are admitted to hospital. If you are unsure please contact the call centre on 0860 00 4367.

Emergency medical response by road or air to the scene of a medical emergency; Transfer by road or air to the closest, most appropriate medical facility; and Repatriation of a patient where medical intervention is required.

Only dial 0800 44 4367;

Give your name and the telephone number that you are calling from; Provide a brief description of what has happened and how serious the situation is; Give the address or location of the incident to assist paramedics to get there; Do not put down the phone until the person on the other side has disconnected. Important points to remember:

- Please ensure that all your registered dependants are aware of this service.

- Inform your child's school that he/she is a member of GEMS. Make sure your child and the school know the emergency medical service number.

Members must phone 0800 44 4367 in all medical emergencies. In instances where a member is transported involuntarily by another service provider (other than Netcare 911) the member must ensure that the service provider submits an invoice to Netcare 911 within 10 days of the service date to facilitate payment of this account.

You must inform the hospital that you are a GEMS member and that any hospital transfers must be authorised by calling 010) 209 8393.