Grintek Electronics Medical Aid Scheme
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Benefits and Contributions

Prescribed Minimum Benefits

PRESCRIBED MINIMUM BENEFIT 100% of cost unlimited
Prescribed Minimum Benefits Subject to PMB protocols
Hospitalisation and Medical Management
(In and out of hospital)

Medicines for PMB conditions
Subject to treatment in DSP or State facility
(For further information call Universal Care - 011 208 1100)

Chronic Medicine Management Programme (registration and preauthorisation)
Tel: 0860 120 312 / chronicmedicine@universal.co.za

Major medical Expenses Benefit (in Hospital)

MAJOR MEDICAL EXPENSES BENEFIT (IN HOSPITAL)
Annual Major Medical Expenses Limit (MME) UNLIMITED
Pre-authorisation is required 48 hours in advance for all elective procedures, failing which a co-payment of R1 800 per admission will apply - Pre-authorisation call Universal Care on 0860 102 312
Private & Public Hospitals, Nursing Homes, Step-down Facilities, Day Clinics & Hospice:
Accommodation in a general ward, high care ward
or intensive care unit; theatre fees
Medicines whilst hospitalised
GP's and Specialists in hospital: Visits, consultations, surgical/ non-surgical procedures, operations including anaesthesia (includes maxillo-facial and oral surgeons)
Radiology and pathology
Blood transfusions
Psychology and psychiatry
Confinements - hospitalisation
Deliveries performed by GP/ Specialist:
- Normal deliveries
- Caesarean deliveries
Surgical/ medical prosthesis and electronic/ nuclear aids used in operations
Clinical technologists
100% AT or contracted fee subject to MME Co-payments are applicable for procedures done in hospital*
100% of cost subject to MME (excludes dental materials)
100% of cost to a max 250% AT subject to MME
(Maxillo-facial and oral surgery excluded except for trauma and PMB cases)
100% of cost to a max 250% AT subject to MME
100% of cost subject to MME
100% AT or contracted fee subject, to MME/ 21 days PMF
100% AT or contracted fee subject, to MME

100% of cost to a max 250% AT/ max 3 days
100% of cost to a max 250% AT/ max 4 days
100% of cost subject to MME, sub-limits apply**
100% AT subject to MME
Hospitalisation Alternatives
Step-down nursing facilities; Hospice

Surgical procedures performed out of hospital in lieu
of hospitalisation

Haemodialysis

Chemotherapy and radium treatment

Biological agents
100% AT or contracted fee subject to MME

100% of cost to a max 250% AT subject to MME

100% AT subject to MME

100% AT subject to MME

100% AT subject to MME, limited to R262 810
Scans Pre-authorisation Required - Call 011 208 1100
MRI and computerised Axial Tomography
High resolution CT scans
100% AT subject to MME
80% AT subject to MME
Ambulance Services 100% AT
ER 24 Emergency Services Call 0800 127 614 or 084 124

* See section on co-payments
** See section on sub-limits

Day-to-Day Benefits (Out of Hospital)

DAY-TO-DAY BENEFITS (OUT OF HOSPITAL)
1. Unlimited Benefit
- GP Consulations (Excluding producures & materials) 90% AT
- Conservative & restorative dentistry treatment 90% AT
2. Annual Flexi-Benefit (AFB)
Day-to-day claims are paid at 90% of the agreed tariff (AT) from the (AFB) M
R9 844
M+1
R15 495
M+2
R18 782
M+3
R21 322
M+4+
R22 804
- Specialists 90% AT, subject to AFB
Consultations and visits
Member must get a referral from the GP before the visit to the Specialist. If no referral is obtained a 10% co-payment will be applicable
M
R2 862
M+1
R5 836
M+2
R8 956
M+3
R9 748
M+4+
R9 992
- Dental Services 90% AT, subject to AFB
 Specialised (crowns, bridgework, orthodontics) M
R7 298
M+1
R11 496
M+2
R13 980
M+3
R16 120
M+4+
R17 045
- Prescribed Medication & Injection Material 90% of cost, subject to AFB and MMAP
Acute and homeopathic medication (Includes vaccinations) Subject to AFB
Chronic Medication
- Non-PMB medication
- PMB medication
Subject to AFB

Unlimited, 20% co-payment for non-formulary medication
Pharmacy Advised Therapy - Limited to R210 per script M
R1 170
M+1
R1 870
M+2
R2 750
M+3
R3 430
M+4+
R4 010
- Optical Services 90% of SAOA, subject to AFB
Lenses, contact lenses, disposable lenses
- Single vision and contact lenses
- All other lenses

Frames

Optometrists - eye examinations

Radial Keratotomy / Excimer Laser
Limited to a maximum of R8 938 PMF

90% of SAOA tariff / R2 562 PB
90% of SAOA tariff / R3 476 PB

90% of cost / R1 460 per case -excluded from    lens limit

90% of SAOA tariff / 1 test PB year
90% AT limited to R5 994 per eye and pre-authorisation

Auxiliary Benefits

3. Auxiliary Services 90% AT limited to PMF
Chiropractors; Naturopaths & Homeopaths; Chiropodists / Podiatrists; Physiotherapy; Audiologists/Speech & Occupational Therapists;
Dieticians; Acupuncturists; Radiology & Pathology;
Orthoptists; Biokinetics;
Private Nursing at home (excluding post-partum cases)
M
R11 185
M+1+
R14 996
- Psychology & Psychiatry 90% AT limited to R8 690 PMF, subject to auxillary services limit
- Medical Appliancess 90% of cost subject to auxillary services limit
Wheelchairs, hearing aids, nebulisers,electronic / nuclear
appliances, prosthesis and ancillary apparatus

Contributions 2019

CONTRIBUTIONS WITH EFFECT FROM 01 JANUARY 2019
Income PM Group Principal Member Adult Dependant Child Dependant
Up to R4 724
R4 725-R6 299
R6 300-R8 399
R8 400-R10 499
R10 500-R15 749
R15 750-R19 999
R20 000-R29 999
R30 000+
A
B
C
D
E
F
G
H
R1 770
R2 379
R2 756
R3 134
R3 235
R3 398
R3 583
R3 599
R1 321
R1 763
R2 060
R2 350
R2 422
R2 556
R2 696
R2 707
R435
R581
R667
R740
R784
R813
R857
R861
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Surgical & Medical Prosthesis Sub-limits

SURGICAL & MEDICAL PROSTHESIS SUB-LIMITS
Subject To MME & Limits Below For 2019
Stents (max of 3 stents)
Medicated stents (maximum of three stents)
Abdominal aortic aneurysm stents
Hip prosthesis
Knee prosthesis
Shoulder prosthesis
Spinal instrumentation (Per level, limited to 2 levels and one procedure PB per year)
Spinal cages
Imported lenses
Heart valves (Mitral etc)
Intra ocular lenses (per eye)
Normal bladder sling
R16 242
R25 100
R73 716
R57 595
R48 742
R48 742
R32 495
R16 242
R11 810
R32 495
R7 386
R11 808
Artificial Limbs
Through knee prosthesis
Below knee prosthesis
Above knee prosthesis
Partial foot prosthesis
R73 840
R56 104
R64 974
R28 064
Electronic & Nuclear Devices
Defibrillator
Single pacemakers
Dual pacemakers
Internal nerve stimulators
Cochlear implant
R177 215
R66 465
R81 228
R147 682
R187 544

Co-payment for In-Hospital Procedures

CO-PAYMENT FOR IN-HOSPITAL PROCEDURES
Co-payment of R1 800 payable for procedures done in hospital (as opposed to a day surgery facility). Should the procedures below be done in a day surgery facility no co-payment will be charged.
Colonoscopies
Cystoscopies
Functional nasal surgery
Gastroscopies
Hysteroscopies (but not endometrial ablations)
Myringotomies
Flexible sigmoidoscopies
Tonsillectomies and adenoidectomies
Varicose vein surgery
Arthroscopies
Diagnostic laparoscopies
MEMBER  GUIDE
 
ABBREVIATIONS
AFB
AT
CDL
DSP
MRP
MME
PB
PMB
PMF
SAOA
Annual Flexi Benefit
Agreed Tarif
Chronic Disease List
Designated Service Provider
Mediscor Reference Price
Annual major medical expenses limit conditions
Per Beneficiary
Prescribed Minimum Benefit
Per Member Family
South African Optometric Association
MEMEBERSHIP
Membership is restricted to eligible employees of Saab SA (Pty) Ltd, all subsidiaries and such associated companies as approved by the Board of Trustees
Registration of Dependants
A member may apply for the registration of his/her dependants at the time of applying for membership.
The following persons can qualify as a dependant:
  • A spouse or partner
  • Dependant children under the age of 21
  • Dependant children over the age of 21 but under the age of 25 and who are students at a recognised tertiary educational institute
  • Immediate family for which the members is liable for family care and support (proof of legal duty required)
  • Disabled / mentally challenged children
Members may add a dependant by completing the necessary form. The following information is required:
  • Previous medical scheme membership certificates
  • Copy of ID's for adults and birth certificates for children
  • Marriage certificate
  • An affidavit where surnames in partnered relationship differ
  • Adopted children - legal documentation to be provided
  • Student certificate and /or proof of registration from a registered tertiary educational institute
  • Proof of dependency when child is over 21
The dependants of a deceased member, who are registered with the scheme as his/her dependants as the time of such member's death, shall be entitled to continued membership of the scheme
Students & Children Older than 21 Years
Children above the age of 21 years are regarded as adult dependants, unless they are studying at a recognised secondary or educational institution. A member should submit annual proof of registration for their dependants who are still studying at an educational institution. The dependant will be regarded as a child dependant The dependant will be removed from the scheme should the required documentation not be received timeously.
Membership Card
Every member shall receive a membership card which must be exhibited to the supplier of a service on request. It remains the property of the scheme and must be returned to the scheme on termination of membership. Members will receive cards for each adult dependant registered. Members may apply for additional cards or replacement cards.
Change of address
A member must notify the scheme within 30 days of any change of address including his/her domicilium citandi et executandi (address at which legal proceedings may be instituted). The scheme shall not be held liable if a member's rights are prejudiced or forfeited as a result of the member neglecting to comply with the requirements of this rule.
Resignation
A member who, in terms of the conditions of employment is required to be a member of the scheme, may not terminate membership whilst still an employee without prior written consent from the employer.
CONTRIBUTIONS
Contributions shall be due monthly in arrears, as stipulated in the rules. Where contributions or any other debt owing to the scheme has not been paid within three days of the due date, the scheme shall have the right to suspend all benefit payments in respect of claims which arose during the period of default.

In the event that payments are brought up to date, and provided membership has not been cancelled, benefits shall be reinstated without any break in continuity. If such payments are not brought up to date, no benefits shall be due to the member from the date of default and any such benefit paid will be recovered by the scheme.
Members' Portions
Members’ portions arise when healthcare service providers are refunded in full by the scheme, but the member still has to cover the cost of a co-payment applicable to the particular benefit or where levies are imposed. Thereafter, claims will be refunded at the AT and any co-payments will be collected at the point of sale at pharmacies.
PAYMENT OF CLAIMS
GEMAS has a weekly payment run to suppliers and members. Members will receive a monthly statement containing details of all payments made to suppliers.
Members can track the payment of their claims on the scheme’s website: www.gemas.co.za
Submission of Claims

Claims may either be submitted electronically by the supplier to the scheme or by the member.
Paper claims may be faxed, e-mailed or posted to details below:
Fax:          011 208 1028
E-mail:    
gemas@universal.co.za
Post:         Private Bag X1897, Rivonia, 2128

MEDICATION
  • A 20% co-payment is payable for the voluntory use of non-formulory PMB medicines and non PMB medicines.
  • Medication must be obtained from a DSP as specified in the Rules of the Scheme.
Medication Pre-authorisation
GEMAS uses Mediscor as its Pharmaceutical Benefit Manager to perform real time electronic processing of its members medicine claims. Mediscor can be contacted on the following numbers:
Switchboard     086 011 7705
Website           www.mediscor.net

Members are required to fax or email chronic medication prescriptions to Mediscor to receive the chronic benefit.
To obtain your chronic medication, you, your doctor or your pharmacist need to contact Mediscor's chroniline or access their website. You need to contact Chroniline every time your chronic medication prescription or dosage is changed by your doctor.
The authorisation from Mediscor is valid for one year. Once the authorisation has expired, you are required to re-authorise your chronic medication prescription.
Maximum Medical Aid Price (MRP)
GEMAS has chosen to settle medicine claims at cost, subject to the Mediscor Reference Price. The MRP is a list of generic equivalent medicines that are available at a substantially lower cost than that of the original medicine and can extend the value of a member’s benefit.
Generic Medicines
A generic medicine is the equivalent of a well-known pharmaceutical product with proven efficacy and safety, that has been utilised over an extended period of time, and of which the patent has expired. Such a generic medicine has the same active ingredient as the original pharmaceutical product and is supplied in the same strengths and dosage forms.
PRESCRIBED MINIMUM BENEFITS
  • Hospitalisation - all services are paid at 100% of cost in terms of PMB criteria and are subject to pre-authorisation & protocols.
  • Medication is subject to the Scheme's formulary, must be dispensed by a DSP and subject to MMAP.
  • Benefits are subject to treatment protocols.
  • All medical services must be supplied by DSP's as specified in the Rules of the Scheme.
HOSPITALISATION
  • All treatment received in hospital is subject to pre-authorisation, case management and Scheme protocols.
  • In the case of elective admissions, authorisation shall be obtained from the Scheme's designated agent at least 48 hours prior to a beneficiary being admitted to a hospital or day clinic (except in the case of emergency), failing which a co-payment of R1 800 per admission shall apply.
Hospital Utilisation Management
Universal Care is contracted by GEMAS to manage the hospital utilisation management pre-authorisation process and care received by members and beneficiaries. Members are required to call (011) 208 1100 for pre-authorisation for all urgent and elective procedures 48 hours in advance and for an emergency admissions on the first working day following the admission. On requesting pre-authorisation for a hospital admission membership, benefits and medical appropriateness are all verified and an authorisation number is issued. Guidance and advice will also be provided to patients with respect to the proposed procedure or treatment. Motivations for treatment may be requested from the treating doctor. The call centre is staffed by trained nursing staff.
Trauma Expense Recovery
Universal Care has designed a unique system to recover money from the Road Accident Fund (RAF). By splitting the claim for medical expenses and personal injury, recovery of the medical expenses can be speeded up. Should any member be involved in an accident they can contact Universal Care on 011 208 1100 and speak to an agent who will advise on all the correct procedures to be followed.
FRAUD DETECTION
Fraud is a major problem in South Africa and the healthcare area is no exception. If you are aware of any fraudulent activity or have any information, please fax Universal on 011 807 6165.
SPECIAL LIMITATIONS
  1. All benefits are pro-rated during the first year of membership.
  2. The following limitations include all services rendered i.e. hospitalisation and related services, and are subject to the limits below in a private institution. Where a benefit is part of the statutory prescribed minimum benefits, treatment in State facilities will be paid in terms of the prescribed minimum benefits criteria.
  3. In cases where a specialist, except an eye specialist or gynaecologist, is consulted without the recommendation of a general practitioner, a copayment of 10% will apply.
  4. In order to qualify for benefits, claims must be received at the Scheme's offices within four (4) months after the end of the month in which the treatment occurred.
EXCLUSIONS
The following exclusions will apply to a member and/or his dependant/s unless that particular exclusion is covered under the statutory prescribed minimum benefits and the treatment is supplied via a State facility unless otherwise decided by the Board.
  1. All costs of whatsoever nature for the treatment of sickness, conditions, or injuries sustained by a member or a dependant and for which any other party may be liable, unless the Board is satisfied that there is no reasonable prospect of the member or dependant recovering adequate damages from the other party. In the case of such a claim, after deliberation is repudiated by the parties concerned, the member is entitled to such benefits as would have applied under normal conditions, irrespective of the lapse of time.
  2. Expenses incurred by a member or dependant in the case of or arising out of wilful self-injury, professional sport, speed contests and speed trials.
  3. Operations, treatments and examinations for obesity, cosmetic purposes, or of the member’s own choosing where this has no connection with any illness, presumed illness, accident or other medical disability. In this regard (but without derogation of the aforegoing), no benefits will be paid in respect of any examinations, operations or surgical procedures relating to jaw, ear, eye-lids or abdomen without approval of the Board.
  4. Holidays for recuperative purposes.
  5. The purchase of: patent medicines and proprietary preparations; applications, toiletries and beauty preparations; bandages, cotton wool and similar aids; patented foods, including baby foods; contraceptives and apparatus to prevent pregnancy; tonics, slimming preparations and drugs advertised to the public; household and biochemical remedies; vitamins and mineral supplements.
  6. All costs that are more than the annual maximum benefit to which a member is entitled in terms of the Rules of the Scheme.
  7. In cases of a protracted nature, the Board shall have the right to insist upon a member or dependant consulting any particular specialist the Board may nominate in consultation with the attending practitioner. In such case, if the specialist’s proposed treatment is not acted upon, no further benefits will be allowed for that particular illness.
  8. Costs for services rendered by:
    1. Persons not registered with the South African Medical and Dental Council; Chiropractors, Homeopaths and Allied Health Service Professions Council of South Africa; South African Nursing Council;
    2. Any institution, except a State or Provincial Hospital, not registered in terms of any law.
  9. Appointments cancelled or not kept by members.
  10. Travelling expenses other than ambulance services.
  11. Hospital or nursing home expenses where free hospitalisation has been obtained.
  12. Private nursing fees in respect of both mother and child in post-partum cases.
  13. Artificial insemination of a person as defined in the Human Tissue Act 1983 (Act No. 65 of 1983).
WAITING PERIODS
If a member does not have continuous membership, the scheme will impose a 12-month waiting period on a preexisting medical condition/s, for that specific condition/s.
IMPORTANT NOTICE
This is a summary of benefits, which are applicable in terms of the rules of the scheme. A copy of the rules may be obtained from the administrators if required. GEMAS does not provide international medical cover.

PLEASE NOTE: The Rules of the Scheme which is subject to the approval of the Registrar of Medical Schemes, will always take precedence over this summary.
Wellness Benefits (claims are paid from Risk and not Subject to AFB))
Benefit Limits
Universal 360° check including: Blood pressure, cholesterol, glucose, BMI, waist circumference, exercise plan, meal plan Limited to R132 PB. 1 per year PB over the age of
18 years at DSP
Childhood immunisations Applicable to children up to the age of six years, as per recommendation of the Department of Health
Baby wellness visit Two visits per annum for children between 4 weeks and 18 months at a DSP
Flu vaccinations Limited to R90 PB
HPV (Cervical Cancer) One course (3 doses per registered schedule) per
female beneficiaries between the ages of 12 and 18
Adult Pneumococcal Vaccine
Subject to pre-authorisation, for beneficiaries over the age of 60
Tetanus vaccine
One injection when required
Malaria prophylaxis As required
Mammogram
One test per female beneficiary over the age of 35,
every 24 months
Pap smear One test per female beneficiary over the age of 18 per annum
Prostate Specific Antigen (PSAs)
One test per male beneficiary over the age of 40 per annum
Annual fitness assessment
At a biokineticist, applicable to beneficiaries over the age of 21
Nutritional assessment
At a dietician, applicable to beneficiaries over the age of 21
Dental check-up
One test per annum
Quit smoking programme
Limited to R3 140, once in a lifetime. Cost of programme will be refunded after cotinine test proves beneficiary is no longer smoking
CONTACT US
Universal Healthcare Administrators (Administrative)Mediscor(Medication authorisation)
Contact number
Fax number
E-mail
Postal address

Website
011 591 8207
011 208 1028
gemas@universal.co.za
Private Bag X1897
Rivonia, 2128
www.gemas.co.za
Contact number
Fax Number
E-mail
Postal address

Website
086 011 7705
012 674 8001
preauth@mediscor.co.za
PO Box 8796,
Centurion, 0046
www.mediscor.net
Universal Care (Hospital pre-authorisation) Emergency Services (Emergency rescue)
Contact number
Fax number
E-mail
Postal address

Website
011 591 8207
0862 957 355
preauthorisation@universal.co.za
PO Box 2570,
Rivonia, 2128
www.gemas.co.za
Contact number 0800 127 614 or 084 124
Council for Medical Schemes - Complaints
Contact number
E-mail
Website
086 111 3267
complaints@medicalschemes.com www.medicalschemes.com