Grintek Electronics Medical Aid Scheme
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Abbreviations

PMB Prescribed Minimum Benefits
MMAP Maximum Medical Aid Price
AFB Annual Flexi Benefit
CDL Chronic Disease List
SAOA South African Opthalmology Association
Auxiliary services Associated Medical Services e.g. speech therapy
*Scheme rate **Agreed Tariff
MRP Medicine Reference Pricing
GEMAS Grintek Electronics Medical Aid Scheme

How to Claim

Please note that although suppliers of health care services may submit accounts electronically, by post, fax or email, it remains the member’s responsibility to ensure that their claims reach the Scheme’s registered offices within 4 months from the treatment date and to check their remittance advices for accuracy and validity of the supplier’s claim.

Electronic claims:

Most suppliers i.e. Hospitals, Pharmacies and General Practitioners, etc. submit claims electronically and members do not have to submit such claims. It however remains the member ’s responsibility to ensure that the claim reaches the Scheme within four months from treatment date and to check remittance advices for accuracy and validity of the supplier’s claim.

Paper claims:

Claims must be submitted within 4 months from date of service and may be faxed, e-mailed or posted to details below:

Fax number:011 208 1028

E-mail:admin@universal.co.za

Grintek Electronics Medical Aid Scheme

Private Bag X1897

Rivonia

2128

Before submitting a claim, please ensure that the following details appear on the account:

  • Membership number
  • Principal member's details (name, address, etc)
  • Supplier's details (name, address, practice number)
  • Treatment date
  • Patient's details
  • Details of treatment (diagnosis, tariff and ICD10 codes, amount charged, etc.)

Please note that although suppliers of health care services may submit accounts electronically, by post, fax or email, it remains the member's responsibility to ensure that their claims reach the Scheme's registered offices within 4 months from the treatment date and to check their remittance advices for accuracy and validity of the supplier's claim.

Grintek Electronics Medical Aid Scheme has two payment runs per month (mid-month and at month-end) to suppliers and members.

Chronic Medication

Prescribed Minimum Benefits (PMBs) and the Chronic Disease List (CDL)

PMBs are a set of minimum benefits which, by law, must be provided to all members by their medical schemes. PMBs must be provided regardless of the benefit option that a member has selected. The medical scheme must pay for the costs of diagnostic tests, treatment and ongoing care.

The Council for Medical Schemes (CMS) has compiled a list of conditions, known as the CDL, for which appropriate medicines and other treatments have been specified. Medical schemes must cover the costs of the specified treatment of CDL conditions from PMB benefits. The medical scheme may make use of clinical protocols, medicine formularies and designated service providers to manage PMB benefits.

The CDL consists of:

  • Addison disease
  • Asthma
  • Bipolar mood disorder
  • Bronchiectasis
  • Cardiac failure
  • Cardiomyopathy
  • Chronic renal disease
  • Chronic obstructive pulmonary disease
  • Coronary artery disease
  • Crohn disease
  • Diabetes insipidus
  • Diabetes mellitus type 1
  • Diabetes mellitus type 2
  • Dysrhythmias
  • Epilepsy
  • Glaucoma
  • Haemophilia
  • HIV/AIDS
  • Hyperlipidaemia
  • Hypertension
  • Hypothyroidism
  • Multiple sclerosis
  • Parkinson disease
  • Rheumatoid arthritis
  • Schizophrenia
  • Systemic lupus erythematosus
  • Ulcerative colitis.

Besides the conditions on the CDL, medical schemes must also cover the costs of the diagnosis and treatment of emergencies and 270 other specified conditions from PMB benefits. More details about PMBs can be found on the CMS website at www.medicalschemes.com/medical_schemes_pmb/index.htm.

Facts about HIV/AIDS

HIV (Human Immunodeficiency Virus) is a virus that affects the body by destroying the body's immune system. The immune system is the body's defense mechanism that helps fight against infections.

The HIV virus is attracted to certain target cells in the body called CD4 cells which are part of our body's immune system. The HIV virus enters and destroys the CD4 cells, reducing the number of CD4 cells over time. This gradually weakens the person's immune system. The person infected with HIV may become increasingly susceptible to infections and cancers as the body's ability to fight infections is reduced.

The virus is mainly present in the following body fluids:

  • Blood
  • Sexual fluids - semen and vaginal secretions
  • Breast milk
  • HIV can only be transmitted from one person to another person through:

  • Sexual intercourse (vaginal, oral or anal) with an HIV infected person
  • Transfer from an HIV infected mother to her baby - through breast milk, pregnancy or through the birth process.
  • Transfer of blood
  • The HIV can still be transmitted from one person to another if a person is on anti-retroviral therapy, even if the levels of the virus are very low. Therefore it is essential for every HIV person to take preventative measures to prevent the transmission of the virus. Unprotected sexual intercourse accounts for 75% to 80% of HIV infections in adults.

There is no cure for HIV, but there is a great deal that can be done to slow the progression of the disease so that you can live a normal healthy life. This includes:

  • Follow a healthy diet
  • Do regular exercise
  • Get regular sleep
  • Reduce alcohol consumption and quit smoking
  • Take a balanced multivitamin/mineral supplement. Avoid supplements that contain very high doses of fat-soluble vitamins (A, D, E and K) and zinc as these may be harmful.

Chronic Medicine Management

To apply, register and update chronic conditions and chronic medicines for the chronic medicine benefit.

Telephone: 0860 117 705, follow the voice prompts for chronic medicine
www.mediscor.net

Fax: 083 295 7305

Email: chronicmedicine@universal.co.za

Abbreviations

PMB                            Prescribed Minimum Benefit

MMAP                        Maximum Medical Aid Price

PMB CDL                   Prescribed Minimum Benefit Chronic Disease List

GEMAS                      Grintek Electronics Medical Aid Scheme

What is the Chronic medicine benefit?

GEMAS offers a separate chronic medicine benefit to fund medicines used for the treatment of chronic conditions.

What is a chronic condition?

A chronic condition is a condition that requires medical treatment on-going or long term. Medicines used to treat the chronic condition are paid from the chronic medicine benefit.

What chronic conditions are covered on my plan?

All four GEMAS plans have an unlimited chronic medicine benefit for Prescribed Minimum Benefits (PMB) CDL conditions specified in the Government Gazette by the Minister of Health. Certain plans may cover additional chronic conditions. GEMAS specifies the list of conditions that are covered on each plan.

GEMAS covers all the PMB CDLs as well as other conditions, as listed below, from the Chronic medicine benefit. Once the Chronic medicine benefit is depleted, your chronic medication may be paid from the ARCB, subject to your available benefits. Once the ARCB benefit is depleted, payment of authorised PMB medicines is unlimited.

PMB CDL
Condition Level A Level B Level C Mzansi
Addisons Disease
Asthma
Bipolar Mood Disorder
Bronchiectasis
Cardiac arrhythmias
Cardiomyopathy
Chronic obstructive pulmonary disease
Chronic renal failure
Congestive cardiac failure
Coronary artery disease
Crohns Disease
Diabetes Insipidus
Diabetes Mellitus Type 1&2
Epilepsy
Glaucoma
Haemophilia
HIV/AIDS
Hyperlipidaemia
Hypertension
Hypothyroidism
Multiple Sclerosis
Parkinsons Disease
Rheumatoid Arthritis
Schizophrenia
Systemic lupus erythematosus
Ulcerative colitis
Multiple Sclerosis
Additional Chronic Conditions
Allergic rhinitis    
Ankylosing spondylitis      
Attention deficit disorder    
Depression    
Gastro oesophageal reflux disease      
Gout    
Incontinence      
Menopausal symptoms – Hormone replacement therapy
Myasthenia gravis      
Osteoarthritis    
Osteoporosis    
Psoriasis    
Vertigo      

How do I apply for chronic benefits ?

  • If your doctor has diagnosed you with a chronic condition, you doctor should apply for chronic benefits for you.
  • The doctor will complete a chronic medicine application form with you.
  • The completed application form and/or a copy of your recent prescription may be faxed or emailed to the Chronic medicine programme. Alternatively your doctor may telephone the Chronic medicine programme directly to register your chronic condition.
  • The request for chronic medicine will be reviewed by the Chronic medicine programme.
  • Clinical Entry Criteria will be applied as your application must meet certain clinical criteria before benefits will be authorised. Your doctor will also provide information on clinical examination information and test results e.g. Blood pressure readings, lipogram test results, HbA1c or glucose results etc.
  • Cover will provided for medicines on the chronic formulary, where the entry criteria have been met. Chronic medicines will be approved from the date that your application is received, provided it is fully completed and includes all supporting documentation.
  • If necessary, the chronic medicine programme will contact your doctor for information regarding your application and/or request your doctor to prescribe formulary medication.
  • The outcome of your application will be communicated to you. If approved you be mailed an Authorisation letter that lists the medicines that will be funded as chronic.
  • You may obtain your approved chronic medicines from one of the GEMAS preferred providers when the authorisation has been finalised.
  • Please ensure that you take a valid repeatable prescription with you when you go to collect your medication.

Chronic Medicine Process

chronic medicine process

What is a formulary?

A Formulary is a list of affordable evidence-based medicines that GEMAS covers for the treatment of your chronic condition. The formulary list is compiled by the Chronic Medicine Management Programme and is constantly reviewed. The Basic formulary applies to Level A, B and C plans, and the Network formulary applies to Mzansi plan.

How do I update my chronic medicine?

If your doctor changes your medication your doctor may call the Chronic medicine programme to update the chronic medicines or you may send a copy of the latest prescription to the Chronic programme.

Do I pay a co-payment on my chronic medicine?

Medicines for PMB CDLs will be covered without a co-payment if they are on formulary for your specific plan. Medicines that are not on the formulary will be subject to a reference price. A MMAP co-payment may still apply if you choose a medicine that has a cheaper generic equivalent.

GEMAS also offers cover for Additional chronic conditions on Level A and B plans respectively. All Additional Chronic medicines are subject to the basic formulary, MMAP and a 20% co-payment.

The PMB CDL and Additional chronic medicines are subject to the Chronic benefit limit. Once the Chronic medicine benefit is depleted, your chronic medication will be paid from the ARCB, subject to available benefits. Once the ARCB benefit is depleted, payment of PMB medication by GEMAS is unlimited.

You can avoid co-payments by the following:

  • Using formulary medicines.
  • Using generic medicine within MMAP
  • Obtaining your medicines from a GEMAS preferred pharmacy.

Formulary Medication

Grintek Electronics Medical Aid Scheme makes use of formularies to manage the cost of the chronic medicines for the Chronic conditions. A formulary is an approved list of medicines used to treat each chronic condition.

What medication falls within the GEMAS formulary:

Please use the following link to establish what medication you can use that is within the GEMAS formulary. This will mean less co-payments from your pocket.

Medicine Formulary:

A medicine formulary is a list of medicines, both generics and the originals, which will be reimbursed by a medical scheme. The medicines on a formulary make up a so-called preferred list of medicines. A medical scheme may only pay for medicines that are on this “preferred” list. Medicines that are not included in the formulary or preferred list are sometimes referred to as “non-preferred” medicines and may attract a co-payment, depending on the particular scheme’s rules.

Mediscor Reference Price (MRP)

The MRP is the maximum price which a medical scheme will pay for a certain medicine. It is usually calculated from the average price of a number of generic medicines which cost less than the original medicine. If a member chooses to buy a medicine that costs more than the MRP, he or she may have to pay in the difference between MRP and the cost of the selected medicine. This is called a co-payment (see “Levy or co-payment”). MRP can apply on both preferred and non-preferred medicines (see “Medicine formulary”). The co-payment on MRP can be avoided by choosing generic medicines that cost less than MRP.

Reference pricing:

Reference pricing is a system that can be used to calculate the price at which a medical scheme will pay for a medicine. Using reference pricing, medicines that are generically or therapeutically the same are grouped together and a maximum price is calculated for that group. Different reference pricing models include the Mediscor Reference Price (MRP), Formulary Reference Price (FRP) and Maximum Medical Aid Price (MMAP®).

The member may have to pay a co-payment if he or she chooses a medicine that costs more than the reference price. The co-payment can be avoided if the member chooses a medicine that costs less than the reference price. The use of the most appropriate alternative should be discussed with a doctor or pharmacist.

Exclusions

1. All costs of whatsoever nature incurred for treatment of sickness conditions or injuries sustained by a member or a dependant and for which any other party is liable.

2. Costs arising from wilfully self-inflicted injuries, professional sport, speed contests and speed trials.

3. All costs for operations, medicines, treatment and procedures for cosmetic purposes,obesity, infertility and artificial insemination. e.g. Bariatric surgery

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
  • Patent foods, including baby foods;
  • Tonics; slimming preparations and drugs as advertised to the public;
  • Household and biochemical remedies;
  • Vitamins and minerals (excluding pregnancy specific supplements and supplements for HIV positive beneficiaries).

6. All costs that exceed the Annual Flexi Benefit in terms of the Rules of the Scheme.

7. All costs in respect of sickness conditions that were specifically excluded when the beneficiary joined the Scheme.

8. Costs for the services rendered by any person not registered with:

  • The South African Medical & Dental Council
  • Chiropractic Association of South Africa
  • Homeopaths & Allied Health Service Professions Council of South Africa
  • South African Nursing Council.

9. Purchase of chemist supplies not prescribed by a person who is legally entitled to prescribe medicine.

10. The cost of gum guards for sports purposes and the use of gold in dental treatment.

11. Costs for services rendered by persons or institutions outside South African borders. However, the Board may consider these on an ex-gratia basis at their sole discretion.

12. Charges for appointments which a beneficiary fails to keep.

Designated Service Providers

Most suppliers i.e. Hospitals, Pharmacies and General Practitioners, etc. submit claims electronically and members do not have to submit such claims. It however remains the member ’s responsibility to ensure that the claim reaches the Scheme within four months from treatment date and to check remittance advices for accuracy and validity of the supplier’s claim.

  • Clicks, Dis-chem, Link, MediRite, ScriptSaver, Optipharm, Optime and Chronic Medicines Dispensary

This means that you may obtain your acute and chronic medicines from any of the above pharmacies without having to make a copayment in respect of dispensing fees or generic equivalents. The arrangement with the above pharmacies relates specifically to the dispensing fee and generic equivalents. It is possible that you may have a co-payment should your doctor prescribe a drug that does not appear on the Scheme’s medicine formulary. You may continue to obtain your medicine from the pharmacy of your choice, it should however be noted that different dispensing fees are being charged by the various pharmacies and this may result in a co-payment if the dispensing fee charged by your pharmacy is higher than that of our preferred providers.

Waiting Periods and Penalties

It is standard in the industry to impose waiting periods and late joiner penalties and is calculated as follows:

1.Waiting periods

Please see the table below for waiting periods as prescribed by the Medical Schemes Act.

Category

3 Month general waiting period

12 Month condition specific waiting period

Application to PMB’s

New applicants, or persons not members for preceding 90 days.

Yes

Yes

Yes

Applicants who were members for less than 2 years.

No

Yes

No

Applicants who were members for more than 2 years.

Yes

No

No

Change of benefit option.

No

No

N/A

Child-dependant born during period of membership.

No

No

N/A

Involuntary transfers due to change in employment or employer changing schemes.

No

No

N/A

2.Late joiner penalties

A late joiner penalty for beneficiaries over the age of 45 may be applied for a maximum period of three years from the date of joining TBMS. Such penalties shall be applied only to that portion of the contribution relative to the late joiner and shall not exceed the following bands:

Penalty Bands Maximum Penalty
1 – 4 years 0.05 x contribution
5 – 14 years 0.25 x contribution
15 – 24 years 0.5 x contribution
25+ years 0.75 x contribution

The following formula shall be applied to determine the applicable penalty band:

A = B – (35 + C)

A = number of years to determine the appropriate penalty band

B = age of the late joiner at time of application

C = number of years of creditable coverage which can be demonstrated.

These penalties may be waived in the event of acquisitions.

Specialist referral

Members and their beneficiaries are required to obtain a referral from a GP before going to a specialist for a consultation and treatment. This is only for out-of-hospital consultations.

The benefits of this initiative are as follows:

  • It ensures that your GP is in control of your healthcare, co-ordinates your health care and has a holistic view of your health.
  • It ensures that only appropriate, complex cases are referred to specialists for treatment.
  • It ensures that referral to the correct type of specialist takes place.
  • The authorisation process will support the process that is used by your GP. When you obtain the referral letter from your GP, the referral letter should be submitted to Universal Health. Based on the referral letter, an authorisation will be created in the administration system. If a referral has been obtained the claim will be paid, subject to limits and the scheme rate.

    The referral letter can be submitted via:

  • E-mail to specauth@universal.co.za;
  • Fax to 086 503 8038;
  • The call centre on 0800 002 636.
  • The authorisation will be:

  • Granted for a period of three months in order to give the member a chance to obtain an appointment with a specialist.
  • Limited to one consultation.
  • For the specialty and not a particular specialist.

    The following will be excluded from the specialist authorisation requirement process:

  1. One gynecologist visit per female, over the age of 16, per annum;
  2. One urologist visit per male beneficiary, over the age of 40, per annum;
  3. Pediatrician consultations for children under the age of 3;
  4. Pregnancies;
  5. Oncology (will be approved as part of the oncology management programme).
  6. Ophthalmologist
  7. Orthodontists