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.