Prescribed minimum benefits

Prescribed minimum benefits

What are Prescribed Minimum Benefits (PMBs)?

Prescribed Minimum Benefits (PMBs) are the basic benefits that GEMS provides for certain medical conditions, such as asthma and hypertension as mandated by the Medical Schemes Act.

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). Also, any emergency medical condition should be considered a PMB. Click here to access a list of all PMB conditions. 

Understanding PMBs 

What are the Diagnosis and Treatment Pairs?

The Diagnosis and Treatment Pairs (DTPs) is a list of the 271 conditions linked to specified treatment that must be funded by all medical schemes. The DTP links a specific diagnosis to the required treatment and broadly indicates how each of the PMB conditions should be treated or managed in a hospital setting. Whilst DTPs are mostly hospital-based, there are some DTPs that are for out-of-hospital management, and of which the treatment may include acute medicines.

When determining whether to fund treatment for these conditions as PMBs, the decision is based 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, whilst also taking affordability into account. A list of these conditions can be obtained from the CMS website.

What is the Chronic Disease List?

The Chronic Disease List (CDL) specifies medication and treatment for 26 chronic conditions for which medical schemes not only have to cover medication, but also doctors’ consultations and certain tests related to the condition. 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. Medical schemes may make use of protocols such as formularies and specific providers, also known as designated service providers (DSPs), to manage this benefit. A list of these conditions can be obtained from the CMS website.

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 medical conditions, including PMB conditions. For the purposes of claims adjudication for PMB, GEMS has selected the State as its DSP for in-hospital services. If you choose to use a healthcare provider other than a DSP for the treatment of a PMB, the scheme may impose a co-payment or limit the rate at which the claim is reimbursed.

Who are the DSPs for GEMS?

Although all GEMS members may access care from any private provider for PMB services, the level of care and services funded as PMB are determined by what is provided by State facilities. The State- hospital is the DSP for GEMS.

You should choose to use the Chronic Medicine Courier Pharmacy and/or contracted pharmacies in the Medicine Pharmacy Network to obtain all chronic medicine (including medicine for HIV) to avoid a co-payment. If you use another pharmacy, a co-payment may apply. You can choose either the Courier Pharmacy or any Network Pharmacy that is within 10 kilometres of your workplace or home, and you are required to remain with the pharmacy 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 a 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 for PMB treatment provided, the Scheme will determine whether you voluntarily or involuntarily made use of the non-DSP. Involuntary use means that: 

  • The service was not available from a 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 you from obtaining such treatment from a DSP; or 
  • The DSP was not within reasonable proximity of your ordinary place of business or personal residence. 

When is it a Medical Emergency?

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, or a co-payment of R1 000 per admission shall apply.

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

GEMS will transfer you to a DSP as soon as it is clinically safe to do so. If you choose not to move, GEMS will only fund the remaining treatment at 100% of the GEMS Scheme rate and could impose a copayment. In other words, claims for the non-emergency portion of treatment will be paid as with any other claim where a beneficiary voluntarily made use of a non-DSP.

To what extent are the Prescribed Minimum Benefits restricted?

  • The costs associated with the diagnosis, treatment, and care of all PMBs will be funded in full if clinical criteria have been met, the service has been rendered by a DSP, and managed healthcare protocols have been adhered to. 
  • 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.


Do I need a pre-authorisation for 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); and
  • 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 (aPMB). Pre-authorisation is not required for these services as these claims will automatically be paid as a PMB where appropriate, and if the correct ICD10 codes are used. The only time a pre-authorisation is required for ambulatory PMBs is if you:

  • Want 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
  • Have 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 can be downloaded from the GEMS website or requested from the GEMS call centre (0860 00 4367).

  • If the application is for additional aPMB 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 your 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 are motivating that the treatment required is not available from a DSP (in which case GEMS will require details of the treatment). 

Please email your signed, completed form, together with any relevant information if required, to enquiries@gems.gov.za, or fax to 0861 00 4367. Your application/motivation will be reviewed, and the decision communicated to you and your treating doctor.

What is an ICD-10 code?

ICD-10 codes are standardised codes developed specifically to indicate what disease or condition you have been diagnosed with and are undergoing treatment for. Your treating provider will include these on a claim and GEMS will use the information to identify whether the claim can be considered PMB. Please note that any diagnostic information included is kept strictly confidential and will not be disclosed to anyone outside the Scheme or the organisations responsible for providing administration and/or managed healthcare services to GEMS. This coding is regulated and is a requirement for any claim to be processed. 



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. Strict clinical guidelines and expert advice are used to ensure that the most appropriate treatment is funded.

  • Funding guidelines (protocols) have been developed for most PMB conditions except for some rare conditions which are managed on a case-by-case basis.
  • They include criteria for validating that a beneficiary has a PMB condition, as well as the reasonable treatment that should be provided for a particular condition.
  • Validation of a particular PMB condition may include determining whether you are registered 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 specifying the number of consultations available from a GP or relevant Specialist, diagnostic tests, and other services that should be funded to treat a condition.