Registered Office:Universal House, 15 Tambach Road, Sunninghill Park, Sandton | Private Bag X1897, Rivonia, 2128, South Africa

Tel +27 11 591 8207 | Fax +27 11 208 1028 | Email gemas@universal.co.za | Web www.universal.co.za

GEMAS Member GuideGrintek Electronics Medical Aid Scheme 2019

1

INTRODUCTION 2

SECTION 1 3WHAT YOU NEED TO KNOW AS A SAAB SOUTH AFRICA EMPLOYEE

Conditions applicable on joining the Grintek Electronics Medical Aid Scheme (GEMAS)Waiting periodsLate joiner penaltiesYour membership to GEMAS will end if:DependantsDependants 21 years and olderChanges/Amendments to your membershipRetired membersRetrenched employeesWidow and orphan membersDivorceYour membership cardBe responsible!

SECTION 2 5HOW DOES GRINTEK ELECTRONICS MEDICAL AID SCHEME WORK?

Description of the benefit optionAnnual Flexi BenefitInsured benefitsRisk benefitsContributions to GEMASClaims submission and your Guide to Problem-Free AdministrationThe following make the claims process easierUseful tips for claimingWhen can you expect to be paid?How will you know what has been paid?How to query a claim or a benefit?What cannot be claimed for?Claims against the Road Accident Fund (RAF) and other third partiesDispute resolution

SECTION 3 8IMPORTANT FACTS AND CONCEPTS

What is an ICD-10 code?Prescribed Minimum Benefits (PMBs)Prescribed MedicationManagement of fraud and abuseBenefit managementWhat is Managed Care all about?Hospital Benefit ManagementWhy is pre-authorisation necessary?Chronic Medicine Management ProgrammeHow to applyMedicine StrategyMaximum Medicine PriceWhat to do in the case of an emergencyUseful tipsDisease management programmes - Back and neck rehabilitation programmeHow does the programme work?Specialist referral and authorisation processDesignated Service Provider

DEFINITIONS 12

PROTECTION OF YOUR PERSONAL INFORMATION 13

GEMASGrintek Electronics Medical Aid Scheme 2019

2

INTRODUCTIONThis booklet has been designed to help you understand the benefits of Grintek Electronics Medical Aid Scheme (GEMAS). Take some time to read through this booklet and familiarise yourself with all the content.

THIS BOOKLET CONSISTS OF THREE SECTIONS.

In Section 1 we look at what you need to know as a SAAB South Africa employee.

Section 2 provides an overview of Grintek Electronics Medical Aid Scheme (GEMAS) – how it works, how to submit your medical claims and matters relating to the payment of your claims.

Section 3 consists of advice on how to manage your benefits effectively, as well as information about the benefit management programmes, and how to control your spending.

The day-to-day management of GEMAS has been contracted to an administrator and the managed care services to a managed care service provider. They work closely with the management of GEMAS to ensure that the services and benefits members are entitled to are delivered to all members. Their contact details are at the end of this booklet.

Definitions have been included on page 12 to explain the technical terms used, and to assist you in understanding exactly how GEMAS and your benefits work.

WEB REGISTRATION PROCEDURE

Members are encouraged to visit the GEMAS website which provides a user-friendly and secure platform to download member statements and tax certificates, and access your claims history.

• To register, go to www.gemas.co.za

• Keep your Grintek Electronics Medical Aid Scheme membership number and ID or Passport number handy as your will need these to secure your online access.

The enclosed Summary of Benefits sets out the benefits offered to you. The information in the Summary of Benefits may change from time to time. You will be issued with an updated copy whenever changes occur.

This booklet is for information purposes only and does not supersede the rules of Grintek Electronics Medical Aid Scheme. In the event of any discrepancy between the booklet and the rules, the rules will prevail.

If you have any queries about any claims you have submitted, please contact GEMAS directly.

3

SECTION 1WHAT YOU NEED TO KNOW AS A SAAB SOUTH AFRICA EMPLOYEEGEMAS is a “closed scheme”, which means that membership is restricted to employees of SAAB South Africa. GEMAS is governed by a Board of Trustees who are all employees and members of GEMAS. The Board of Trustees consists of an equal number of employee-elected trustees and employer-appointed trustees. One of the most important duties of a trustee is to protect the interests of all the members.

CONDITIONS APPLICABLE TO JOINING GRINTEK ELECTRONICS MEDICAL AID SCHEME

It is a condition of employment with SAAB that all employees are a member of a registered medical aid scheme.

Waiting PeriodsWaiting periods will apply when you or your dependents join the scheme and you had a break in medical scheme membership for a period of 90 days or more. Each person joining GEMAS will be evaluated individually on their medical history and then the waiting period will be applied, either in general of specifically to the relevant condition. It is always important for you to be truthful in your application as any conditions found that you were aware of and that was not disclosed on your application may be seen as a non-disclosure which may lead to further action being taken by GEMAS and the company.

Late joiner penaltiesThe Rules of GEMAS allow for penalties to be levied on members and their adult dependants who join later in life and have been set out below. If applied, the late joiner penalty will be based on the number of years after the age of 35 that the applicant was not a member of a medical aid scheme.

In addition to the normal contribution, the late joiner penalty is applied as follows:

Number of years 1-4 5-14 15-25 25+

% of contribution applicable to the main member

0% 5% 25% 50%

% of contribution applicable to the spouse and adult dependent 5% 25% 50% 75%

Any years during which applicants can prove they were members of a medical aid scheme will be subtracted from their current age in determining the penalty.

Your membership of the Grintek Electronics Medical Aid Scheme will end if:• You leave the company or group. • You choose to join your spouses or partner’s medical aid. In the

event of this occurrence, the employee will be entitled to re-join GEMAS should your membership of your spouse or partner’s medical aid cease; penalties may apply.

If you choose to join your spouse or partner’s medical aid, you will need to provide SAAB Human Resources department with a membership certificate, indicating your membership of your spouse or partner’s medical aid.

DependantsYour dependants are eligible to join GEMAS, provided they are not members of other medical aid schemes. The registration of any dependants is subject to the Scheme Rules.

It is important to remember to register your child or spouse within 30 days of the event occurring.

Penalties may apply to their membership if the required documentation is submitted more than 30 days after the event. Contributions will be backdated to the month following the date of birth of your child or the date of your marriage.

Dependants 21 years and olderLetters are generated and sent to members three months prior to the dependant turning 21 years or older in accordance with the following:• A child who turns 21 will be automatically become an adult

dependant, unless the member requests that the child be terminated. Re-registration is not permitted. Any child who remains a member after the age of 21, will be charged for at adult rates.

• A child, over the age of 21 years, who is unmarried, not self-supporting and who is registered as a student at a recognised educational institution and produces proof of registration in the form of a certificate from the institution, shall be registered as a dependant for periods of not more than twelve months at a time until he/she attains the age of 25 years.

• Dependants above the age of 25 years who are registered as physically or mentally disabled and who are, due to their disability, fully financially dependent on the member for care and support, may apply to remain on GEMAS at adult rates.

4

Changes / amendments to your membershipIf your personal details change, it is important to inform GEMAS immediately. Complete the member record amendment forms. The completed forms must be submitted to either GEMAS or your HR department, with all supporting documents, where required. The form must be completed in the following instances:• Change in your personal details (e.g. marriage, birth of a child or

divorce). • Change in your banking details. • Change in your contact details (e.g. your address, telephone

number, cell phone number, email address). • Termination of dependants.

Retired membersRetired members are entitled to the same benefits as in-service members of GEMAS, provided they:• Have reached the minimum retirement age. • Have retired early because of ill health or disability.

Retrenched membersA member whose employment is terminated for reasons related to the operational requirements of the employer may, in the discretion of the Board, be allowed continued membership for a period of up to 6 months after termination of employment, provided that is such a member should obtain alternative employment, his membership shall terminate with immediate effect.

Widow and orphan membersIf you pass away, your spouse and children may continue as members of GEMAS, provided that they were registered as dependants at the date of your passing.

DivorceIn the event of a divorce, your spouse or partner will cease to be classified as a spouse. It is your responsibility to notify GEMAS should you get divorced.

Your membership cardYour membership card is proof of membership of GEMAS. It reflects the following information:• Your membership number. • Your first names and surname. • The names of your registered dependants. • The dates from which you are all entitled to benefits.

Be responsible!Please look after your medical aid card. You must not lend it to anyone except your registered dependants. Using your membership card fraudulently may lead to the suspension or termination of your membership. An additional card is available upon request from GEMAS.

5

Description of Benefit optionThe Scheme continues to provide members with a value for money medical aid scheme. The Scheme offers:• Generous day-to-day benefits (Annual Flexi Benefit)• Separate chronic medicine benefit limit• Freedom of choice in service provider selection• Unlimited overall annual benefit• A wellness benefit – including flu vaccines and mammograms

Annual Flexi BenefitAll out of hospital day to day claims are paid from the Annual Flexi Benefit (AFB) at 90% of the agreed Scheme tariff. All annual limits specified in this section are pro-rated if membership commences during the year.

The following benefits are payable from the AFB, subject to specified sub-limits:• Optical• Acute medicine • Chronic medication. Non PMB• Specialists – referral required• Special dentistry

Insured benefitsTreatments referred to in the summary of benefits as “insured benefits” are paid for out of the insured benefits risk pool. These treatments are paid for at the agreed Scheme tariff. The following benefits are paid from insured benefits:• Unlimited consultations (excluding procedures and materials) paid

at 90% of agreed scheme tariff • Unlimited Conservative and restorative dentistry treatment paid

at 90% of agreed scheme tariff • Auxiliary Services, subject to sub limits, paid at 90% of agreed

scheme tariff, services include chiropractors, naturopaths, homeopaths, podiatrists, physiotherapists, audiologists, speech therapists, occupational therapists, dieticians, acupuncture, radiologists, pathologists, orthoptist, biokineticists, private nursing (excluding post-partum cases) and medical appliances

• Psychology and psychiatry, subject to sub-limits paid at 90% of agreed scheme tariff

• Wellness Benefit, paid at 100% of agreed scheme tariff • Chronic Medicine benefit, PMBs unlimited subject to formulary• Back and neck rehabilitation programme

Risk benefitsAll in-hospital benefits are paid from the Risk benefit. Pre-authorisation is required from Universal Care for all hospital admissions. To ensure that beneficiaries receive cost effective, appropriate care, Universal Care performs pre-authorisation, validation and case management services.

If pre-authorisation is not obtained at least 48 hours prior to a non-emergency hospital admission, or if Universal Care is not advised within 24 hours of the emergency admissions, a R1 800 co-payment will apply. For pre-authorisation, call 0860 102 312.

Risk benefits do not have an overall annual limit however sub-limits apply.

The benefits are reviewed by the trustees annually. You should study your benefits so that you are fully aware of the cover you and your dependants have.

If you join GEMAS during the year you will receive benefits in proportion to the number of months of that year that you will be a member of the Scheme, e.g. six months equals 50% of benefit limits.

The pro-rated benefit limits will not apply if the procedure is for a PMB.

Contributions to Grintek Electronics Medical Aid SchemeContributions to GEMAS are made in arrears and are based on your salary band. The contribution table detailing the current contributions for all members and their dependants will be sent to you separately.

Annually, the trustees of GEMAS set the amount of contributions that will be paid. This is monitored on a regular basis.

The trustees take the following into consideration when reviewing contribution levels:• The financial performance of GEMAS.• Tariff increases for the following year.• The requirements of legislation.

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.

SECTION 2HOW DOES GRINTEK ELECTRONICS MEDICAL AID SCHEME WORKGrintek Electronics Medical Aid Scheme is a closed scheme belonging to the employees of Saab Grintek Defence and Saab Grintek Technologies, exclusively. The Scheme has one benefit option and an income-rated contribution table.

6

Claims submission and your guide to problem-free administrationNothing is more annoying than wondering where your refund is and not knowing when you are likely to receive it. It is very important that you understand how the claims process works at the administrator.• You or your healthcare provider can submit claims to the

administrator. • You should email, post or deliver your accounts as quickly as

possible using one of the following methods: • Electronic submissions by the provider of service Electronic Data

interchange (EDI) (preferred), • Submissions by email: gemas@universal.co.za• Postal address:

Universal Healthcare Administrators (Pty) Ltd Private Bag X1897 Rivonia 2128

• Hand delivery to Universal Head Office at No. 15 Tambach Road, Sunninghill Park.

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.

The following will make the claims process easier:• Send the first account you receive. Do not send statements.• If you have already paid the account, please attach your receipt

and clearly mark the account as PAID on the face of the invoice that we know we should pay you and not the provider.

• Please do not submit accounts marked FOR YOUR INFORMATION ONLY, or accounts showing a balance brought forward. Such accounts are for your records, and should be used to check the payments shown on your claims transaction statements.

• Check your claims transaction statement before submitting a second account. The statement has an explanation of the transaction codes.

• The Medical Schemes Act requires that the supplier of a service provides the following details on all accounts:

• Your name and initials as the principal member. • Your medical aid number.• The name (as shown on the membership card) of the patient. • The treatment date.• The amount charged. • The tariff code and ICD 10 code, where applicable. • Only accounts received for services from an accredited service

provider will be paid. All providers need to be registered with the Board of Healthcare funders (BHF) with a valid practice number for it to be paid.

Please check that your account shows all of the information above before submitting. It is recommended that you keep a copy for your own records.

Useful tips for claiming• The administrator will not be able to process your claim if a

healthcare provider i.e. pharmacy, GP and others leave out important details.

• Check that prescriptions for medicine show all your details and the correct quantity of medication dispensed.

• Dental treatment often requires additional work by a dental technician who bills the dentist, who then adds the amount to your account and attaches a copy of the technician’s account. Please send both accounts to the administrator, and make sure that your name and medical aid number appear on both.

When can you expect to be paid?The administrator has regular payment cycles of up to five payment runs each month to all members and healthcare professionals. All valid claims received by Universal are processed on this basis. When a claim is received, an SMS or an email is sent to you advising you that the claim has been received and has been submitted for payment. It is therefore important that you ensure that GEMAS always has your correct cellphone number or email address so that you can keep track of your claims.

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.

How will you know what has been paid?GEMAS has a weekly payment run to suppliers and members On a monthly basis, you will receive a member statement that will reflect what the administrator has processed on your behalf during that month. This statement will show all the payments made to you or made on your behalf. Check your statements to make sure that all your claims have been processed, that the claims reflected are for services provided to you or your dependants, and that the amount shown is the same as the amount that was credited to your bank account.

Members can track the payment of their claims on the scheme’s website: www.gemas.co.za

Note:• Accounts charged at the scheme tariff will be paid directly and

in full to the supplier (on condition that the amount charged does not exceed your available benefits), unless the claim has been paid by the member, then the reimbursement will be paid directly to the member.

• Accounts charged above the scheme tariff will be paid directly to the supplier at the scheme tariff only. If you have paid the account and have attached a receipt to your claim, you will only be refunded for the scheme tariff amount. You are responsible for paying the supplier the difference between the scheme tariff and the amount charged.

7

How to query a claim or a benefitTo query a claim or benefit, you should phone GEMAS’s dedicated number on 011 591 8207 or email gemas@universal.co.za. The lines are open Mondays to Fridays from 07:00 to 19:00 and Saturdays from 08:00 to 13:00. When querying an account, you must ensure that you are given a reference number. It is advisable that you keep a copy of all claims that you have sent to the administrator and the dates of submission, in case a query arises.

What cannot be claimed for?GEMAS does not cover any costs related to certain treatments of, for example:• Obesity, wilfully self-inflicted injuries, injuries from professional

sports activities, speed contests and trials, and holidays for recuperative purposes;

• Cosmetic surgery, including plastic and re-constructive surgery, and surgery with a definite cosmetic aspect, such as breast reduction or enlargement, removal of excess fat and skin grafts.

• 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.

• Holidays for recuperative purposes• 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

• All costs that are more than the annual maximum benefit to which a member is entitled in terms of the rules of the scheme

• 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

• Costs for services rendered by:• Persons not registered with the South African Medical and

Dental Council; the Chiropractors, Homeopaths and Allied Health Service Professions Council of South Africa; and the South African Nursing Council;

• Any institution, except a state or provincial hospital, not registered in terms of any law.

• Appointments cancelled or not kept by members• Travelling expenses other than ambulance services.• Hospital or nursing home expenses, where free hospitalisation

was obtained.• Private nursing fees in respect of both mother and child in

post-partum cases.• Artificial insemination of a person, as defined in the Human

Tissue Act 1983 (Act No. 65 of 1983).

These are excluded in terms of the GEMAS rules.

Claims against the Road Accident Fund (RAF) and other third partiesGEMAS helps you by paying for medical and hospital expenses incurred as a result of a motor vehicle accident or other incident where a third party is liable. To do this, GEMAS has appointed an attorney that specialises in recovering RAF claims, to help members with the submission and administration of medical claims. In the unfortunate event that you and/or one of your beneficiaries are involved in an accident, this is what you need to do to make a claim:

STEP 1: Let GEMAS or the appointed attorney know about the accident as soon as possible.

STEP 2: GEMAS or the appointed attorney will send you an Accident Report Form. It is very important that you complete the form and return it to the appointed service provider as quickly as possible. This will let the assessors determine whether there are merits to your claim against the RAF. In some cases, you may not be aware that a different party is liable for the payment of your medical costs – that is where the appointed service provider can be a great help.

STEP 3: If your injuries were caused by a third party, our attorney will act on your behalf in order to recover expenses from the RAF. Our attorney will advise you on all aspects of your claim, including items such as loss of income and compensation for pain and suffering, as well as medical expenses.

STEP 4: You and your appointed attorney will need to complete a document that says you will reimburse GEMAS for any monies which may be recovered from the RAF for past medical and hospital expenses paid by GEMAS.

STEP 5: As soon as this undertaking is provided, GEMAS will pay for all medical costs arising from a third party claim. Should you have an existing claim where you have already instructed an attorney, you have a legal obligation to inform GEMAS and the appointed service provider of the claim. Failure to do so will constitute fraud and GEMAS has the discretion to hold you civilly and criminally liable.

Should you face these challenges, do not hesitate to contact our Trauma Department on (tel) 011 208 1168 or email trauma@universal.co.za

Dispute resolutionIn the event that you are not satisfied with a decision made by GEMAS or its appointed agents, you may escalate that to the Board of Trustees. If still not satisfied with the response of the Board of Trustees, you may request that the matter be referred to GEMAS’s Disputes Committee. The GEMAS Dispute Committee will then consider your request. Should you still not be satisfied with the ruling of the Disputes Committee, you can then refer it to the Council for Medical Schemes, the regulatory body that oversees the industry, for their consideration. Contact details for the Council of Medical Schemes can be found at the end of this booklet.

8

What is an ICD-10 code?ICD-10 stands for International Classification of Diseases and Related Health Problems — 10th revision. This is a set of codes developed by the World Health Organization (WHO), which translates the written description of medical and health information into codes in a standardised format, e.g. J03.9 = acute tonsillitis, unspecified and G41.0 = grand mal status epilepticus. This set of codes forms part of an international standard, with which South Africa is required to comply in accordance with the Medical Schemes Act. The ICD-10 code is used to supply the diagnosis or medical condition.

Healthcare providers in South Africa are required by law to include ICD-10 codes on all their claims or accounts, in addition to their treatment codes, such as for consultations, surgery, etc. This requirement applies to all claims – whether the healthcare provider submits the claim directly to the Health Plan, or whether you pay at the time of service and then claim your benefits from the Health Plan yourself. Any claim or account that does not have accurate and complete ICD-10 codes will lead to rejection and non-payment by the Health Plan. Healthcare providers are familiar with the need to include an ICD-10 code on medical scheme claims.

Using ICD-10 codes has the following benefits:• Reliable statistics for medical and health conditions are

obtained, which means that your scheme can plan the correct management of your medical services and benefits.

• Faster payment of your claims. • Correct coding of PMB conditions ensures payment from the

appropriate benefit pool. • Ensuring confidentiality of your condition/illness, since that

information is now supplied to your medical scheme in coded form.

Prescribed minimum benefits (PMBs)The Medical Schemes Act contains a list of prescribed minimum benefits (conditions and procedures) that must be covered by every medical scheme, as a minimum standard of care, and at no additional cost to members.

GEMAS covers the PMB conditions, in private facilities and in accordance with the regulated PMB protocols, as set out in the summary of benefits and contributions.

All of the above are paid for by GEMAS in private sector hospitals and clinics, however, the administrator and managed care service provider will ensure that the care is appropriately managed within the scheme’s rules and benefits and the Council for Medical Scheme’s legal requirements.

This could necessitate transfer of the patient for treatment in an appropriate public sector facility. It is important to use the administrator authorisation process to establish whether a condition or procedure is on the PMB list. The PMB list is available on request from the administrator (contact details are on the back cover).

For more information, please refer to the PMB Guide on the GEMAS website - www.gemas.co.za

Prescribed MedicationDon’t pay for the nameAlways ask your doctor if there is a generic equivalent for the medicine that has been prescribed, as these are much more cost effective. A generic medicine is one that has the same chemical ingredient, strength and formulation (for example tablet, syrup, etc.) as the original product. The Medicines Control Council (MCC) checks each medicine for quality, safety and efficacy before it is registered. Generic medicines offer the consumer medicines that are as effective, but generally cheaper than, the original.

Why are generic medicines cheaper than brand name drugs?Much of the cost of a brand name drug covers the money for research and development. Generic medicines may only come onto the market after the patent protection period for the original drug has expired.

Are generic medicines as reliable as brand name products?Drugs generically equivalent to a brand name must meet strict manufacturing standards set by the Medicines Control Council. Tests must ensure that the generic delivers the same amount of active ingredient to the body at the same time, and is used by the body in the same way, as the brand name product. Basically, generics should produce the same results as the brand name product.

Management of fraud and abuseFraud has become a major issue in the medical aid industry, with schemes losing millions of Rands due to fraud and abuse of the system. The greater the loss incurred through fraud, the higher your contributions become to cover this loss. GEMAS has measures in place to detect and manage fraud and the abuse of benefits. If you are aware of any fraudulent activity or have any information, please fax Universal on 011 807 6165.

Benefit managementTo help you control unnecessary spending, GEMAS has a managed care programmes in place. Making maximum use of these programmes helps to control your medical spending, ensures that your benefits last longer and keeps future contribution increases to a minimum. The following pages provide detail on the most important managed care programmes.

SECTION 3IMPORTANT FACTS AND CONCEPTS

9

What is managed care all about?In recent years medical schemes have begun to look at influencing the suitability, quality and cost of the care that their members receive through the introduction of managed care programmes. This is essentially a holistic approach to promote health, prevent disease and treat existing diseases appropriately according to scientific evidence and cost effectiveness, within a given cost framework.

Managed care programmes manage not only the event in isolation (e.g. the hospital stay or the medicine taken), but also all matters relating to a member’s health. By looking at patient claims, qualified medical professionals can identify members who suffer severely from certain diseases, such as asthma. Patients and their doctors are then invited to participate in educational sessions aimed at helping patients to control their disease.

Hospital benefit managementThis programme ensures that members receive appropriate, quality and cost-effective care while they are in hospital. Members must choose a hospital within the approved network of hospitals that has been established for GEMAS.

Before being admitted for treatment or a procedure in hospital, you must phone the Manage Care Agent, Universal Healthcare, on 011 208 100 to request an authorisation at least 48 hours before admission. Based on the information supplied to the Manage Care Agent, if an admission is approved, a pre-authorisation number will be issued, which you must produce on admission to the hospital. If you don’t comply with this, you could incur a financial penalty according to the rules of GEMAS.

When you phone the administrator you need to have the following information available:• Your membership number.• The name and dependant code of the person being admitted. • The reason for admission.• The diagnosis code (ICD-10 code).• The name of the procedure or the doctor’s codes should you be

undergoing surgery.• The date of admission and scheduled date for the operation or

procedure.• The doctor’s name, telephone number and his practice number,

if you have it.• The name of the hospital and its practice number, if you have it.

You may also email your request through to preauthorisation@universal.co.za, or fax it through to 0860 102 312. Your doctor or the hospital may also phone and request a pre-authorisation on your behalf.

Remember that the administrator applies the rules of GEMAS and will only authorise procedures that are covered in terms of the rules.

Most hospitals facilitate the approval for pre-authorisation, however, a family member or friend may also phone on your behalf.

Why is pre-authorisation necessary?• To protect you from undergoing any unnecessary treatment or

procedure.• To provide you with information and advice relating to the

treatment and guide you on what to expect during your stay in hospital.

• To provide you with information relating to the costs for the procedure and how much will be covered by GEMAS.

• To manage hospital costs by making sure that GEMAS pays only for appropriate treatment.

Important• Once admitted to hospital, should your treating doctor require

you to remain in hospital for additional days, these need to be authorised. The hospital will phone the administrator to arrange this.

• When obtaining authorisation for a procedure, the administrator will provide approval for the required procedure. They are not guaranteeing the payment of the account. Reimbursements will be made at the scheme tariff and according to the rules of GEMAS.

Chronic Medicine ProgrammeIf you are using chronic medication to treat a chronic condition, you should apply to be registered for the chronic benefit. Your chronic benefit covers:• Medicines for life-threatening illnesses (e.g. hypertension). • Medicines used on an ongoing basis to treat disabling

chronic illnesses that significantly affect productivity and quality of life (e.g. arthritis).

• Very expensive short-term medicines that prevent more expensive treatment such as hospitalisation.

The GEMAS Chronic Medicine Programme authorises payment for the most appropriate and cost-effective medicine from your chronic medicine benefit. The GEMAS Chronic Medicine Programme ensures that members effectively manage their chronic condition, by assessing whether the medicines prescribed are appropriate for the condition and identifying less expensive but equally effective medicines. If you are not sure whether your medication will qualify, please contact the GEMAS Chronic Medicine Programme.

How to apply for chronic medicine benefitsEither the patient, the prescribing doctor or the pharmacist can contact the Chronic Medicine Programme on 0860 102 312 to register a chronic condition, apply for chronic benefits or to change a chronic medicine. You can also email your chronic prescription to chronicmedicine@universal.co.za. The Chronic medicine programme will review the chronic medicine request. Once your request has been reviewed by the chronic medicine programme, you will receive an authorisation letter confirming your chronic registration. When obtaining your chronic medicines from the pharmacy, please remember to show them your authorisation letter, together with your doctor’s prescription.

If your doctor wishes to amend your chronic treatment, the changed prescription may be sent to the chronic medicine programme or your doctor may contact the chronic medicine programme on the contact details listed above.

10

Medicine strategyGEMAS participates in a medicine strategy that aims to keep the cost of medicines in check.

Maximum medicine priceMedicines are classified according to groups and a price limit* has been allocated to each group. Within each medicine group, the price of different products could vary between, for example, R20 and R80. The price limit is set at the level of the most cost-effective medicine in the group, which in the example is R20.

If you prefer the R80 product, you will have to pay the difference (i.e. R60) to the provider when you buy the medicine. At least one medicine in each group will be fully paid for – no co-payment will be required. This will typically be the generic equivalent.

A 20% co-payment is payable for the voluntary use of non-formulary PMB medicines.

*The price limit applies to both your acute and chronic medicine benefits.

Note:The reference price limit does not apply to every group of medicines (for example where the medicine is still under patent and no generic is on the market). If you are currently taking or are prescribed such medicine, for which there is no generic equivalent, you will be covered for this medicine without having to make a co-payment.

To help you avoid co-payments, please ask your doctor to prescribe generic medicines wherever possible.

Designated service providerIn terms of the Medical Schemes Act, medical schemes are allowed to appoint a designated service provider (DSP) for the provision of the ambulance benefit, namely ER24.ER24 offers a 24-hour/7 days a week integrated service to all its clients. The clinical staff are all highly specialised in emergency care and include friendly and helpful professional nurses and paramedics.

Medical Information and Assistance Line – 084 124 ER24 Medical personnel, including doctors, paramedics and nurses, will be available 24 hours a day to provide general medical information and advice. This is an advisory and information service, as a telephonic conversation does not permit an accurate diagnosis.

24 hour “Ask the Nurse” Health Line• Members are encouraged to utilise this 24-hour cost-saving service.• Our trained medical staff use documented medical algorithms

and protocols to advise members on healthcare solutions.• Members can first seek advice as to:

• Urgency of attention needed: dispatch ambulance, go to the hospital, go to the doctor.

• Generic medication advice: go to the pharmacy for over-the-counter medication;

• Self-medicate from home.

What to do in the case of an emergency• Call 084 124.• If someone else is calling on your behalf, tell them to call

084 124.• Tell the ER24 operator that you are a Tiger Brands Medical

Scheme member – they will prompt you or the caller for all the information they require to get help to you.

Useful tips• Teach your family members to call 084 124 in case of an

emergency.• In an accident, take note of road names and numbers as this will

expedite the emergency services.

Trauma linesIn addition, the members have access to a 24-hour Crisis Counselling line where trained healthcare professionals will telephonically assist with advice/counselling for:• Domestic violence - Family, domestic and child abuse• Bereavement• Hijacking• Armed robbery• Assault• Kidnapping• HIV/AIDS information• Trauma counselling• Rape/referral to rape centres• Substance abuse• Poison advice• Suicide hotline

Disease management programmes – Back and Neck Rehabilitation ProgrammeBack and Neck Rehabilitation Programme – a managed care programme adopted by the Scheme for the management of beneficiaries identified with back and neck conditions. Defined care pathways are used by the two DSPs for this programme namely, the contracted Document Based Care (DBCs) group and contracted physiotherapists who are accredited members of the Physiotherapy Association of South Africa, for the active treatment and rehabilitation of back and neck problems.

The Scheme will impose a R3 000 hospital co-payment should an eligible member or beneficiary decline to follow the Back and Neck Rehabilitation Programme prior to going for non-PMB or non-emergency PMB spinal surgery.

11

How does the programme work?• If you are diagnosed with a back or neck condition you will be

contacted by a nurse counsellor and invited to join the Back and Neck Rehabilitation Programme.

• Once you are enrolled on the programme, the nurse will contact you telephonically to offer information, advice and support regarding your condition which will enable you to play an active role in the management of your condition.

• A health brochure will be emailed or posted to you, which will also provide information on your specific condition

• The nurse counsellor will schedule regular follow-up calls to you• The counsellor will monitor your compliance with your treatment

plan, and this may include checking that you go to your doctor regularly for follow-up visits, and that you have specific tests done that are important to manage your condition.

You can contact 0860 102 312 or diseasemanagement@universal.co.za for more information.

Specialist referral and authorisation processMembers 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 0866 151 509• 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 speciality and not a particular specialist.

The following will be excluded from the specialist authorisation requirement process:• One gynaecologist visit per female, over the age of 16, per annum;• One urologist visit per male beneficiary, over the age of 40, per

annum;• Paediatrician consultations for children under the age of 3;• Pregnancies;• Oncology (will be approved as part of the oncology management

programme).

In cases where a specialist, except an eye specialist or gynaecologist, is consulted without the recommendation of a general practitioner, a co-payment of 10% will apply.

12

ADMINISTRATOR

The administration of GEMAS is contracted to a professional administration company.

They are responsible for maintaining a record of all members who have joined GEMAS, raising and collecting contributions, processing and paying claims, as well as providing a call centre to answer any queries you may have.

They also maintain the financial records of GEMAS and interact with the regulator on matters affecting GEMAS. Universal Healthcare Administrators (Pty) Ltd has been appointed to perform this function.

ACUTE MEDICATION

Medicine for the treatment of short-term medical conditions, such as colds and flu.

CHRONIC MEDICATION

Medication you take on an ongoing basis to treat a life-threatening condition or to relieve the symptoms of an ongoing condition, such as diabetes, hypertension or asthma.

DEPENDANTS

Your dependants are your immediate family members for whom you are responsible for family care and support, as stipulated in the rules of GEMAS.

MANAGED HEALTHCARE

Managed healthcare is the process of applying clinical protocols to treatment proposed for members. The role of a managed healthcare company is to ensure that the treatment a patient receives is clinically appropriate, meets international clinical guidelines and is cost effective. GEMAS has contracted Universal Care (Pty) Ltd to perform this function.

SCHEME TARIFF

This is the fee that the scheme reimburses service providers for healthcare services and procedures. Healthcare providers may set their own fees but the scheme sets a maximum value for reimbursement of these services.

PHARMACIST-ADVISED THERAPY (PAT)

PAT medicines are those medicines that are recommended by your pharmacist and that may be obtained without a doctor’s prescription. The medicines are used to treat minor ailments.

PRESCRIBED MINIMUM BENEFIT (PMB)

A minimum level of cover or benefit that medical schemes must provide to their members, which is equal to what is provided in State facilities, as defined in the Medical Schemes Act 131 of 1998 and Regulations.

PRIVATE RATES

These rates are higher than the scheme tariff, and are determined by individual service providers or groups of service providers.

DEFINITIONS

13

The confidentiality of your personal information is important to GEMAS, and no compromise is ever a consideration.

Personal information refers to information that identifies you or relates specifically to you or your dependants, such as an identity number, name, telephone numbers, email address or medical condition.

We will always strive to keep your personal information and that of your dependants confidential, whether you supplied it to us directly or whether we have collected it from other sources.

We thus want to make sure that you understand how we will process your information. To service your membership, GEMAS will use your information and that of your dependants in different ways. These include:• verifying your identity • processing your application for membership • administration of your medical scheme membership • assessment, processing and reimbursement of claims for

medical expenses • determining your entitlement to benefits • underwriting or risk assessments • providing relevant information to a healthcare provider who

requires this information to provide a healthcare service to you or any of your dependants

• providing managed care services to you or any of your dependants • sharing your information with service providers, including electronic

switching houses, for the purpose of processing it and rendering services to you such as electronic submission of claims to us

• risk management practices • fraud prevention and detection • audit and record keeping purposes • compliance with legal and regulatory requirements • collection of monies owed by your or healthcare providers to us • statistical analysis (this will always be on an anonymous basis,

which means that data about you that is relevant to the analysis is used but it is not linked to your name or membership number).

If we want to share your information, for any other reason, we will only do so with your permission, or unless we are permitted or required to do so by law.

Your information will not be sold for commercial purposes.

We value your personal information and to this effect have implemented a number of processes to make sure it is used in the correct way. That is why, if you think we have used your personal information in a way that is illegal, you can speak to us about it and we promise to investigate the matter.

The accuracy of your personal information is also important to us and you can always ask us for details about the information we have on record for you. If your information is outdated, you can ask us to update or correct it.

We have also taken reasonable steps to protect your personal information from loss, misuse or unauthorised alteration. We vouch that we have adequate data security measures in place, with restricted access to your data, data back-up systems and data recovery systems.

We confirm that all staff within GEMAS are bound by signed confidentiality undertakings. We have ensured that confidentiality agreements have been entered into with all contracted third parties who have access to your information for the purpose of data transfer and management, scheme administration and managed care arrangements.

In the event of a breach of confidentiality, we shall assume responsibility if we are at fault and will manage the breach according to our internal protocols and disciplinary procedures.

Apart from you giving us personal information about you and your dependants, there are other sources that we may also get information from, such as doctors, hospitals or other healthcare providers. These sources are bound by their own promise to look after your information and make sure it is used in the correct way.

Grintek Electronics Medical Aid Scheme will use your contact information to notify you of new products or developments on products you already have with us. If you do not want to receive this kind of communication from us, you can ask us to stop this communication.

PROTECTION OF YOUR PERSONAL INFORMATION

Administered by:UNIVERSAL HEALTHCARE ADMINISTRATORS (PTY) LTD

CONTACT DETAILSCall Centre (general telephone queries)Tel: 011 591 8207 / Email: gemas@universal.co.za

Hospital Benefit Management (hospital pre-authorisation)Tel: 0860 102 312 / Email: preauthorisation@universal.co.za

Chronic Medicine Management Programme (registration and pre-authorisation)Tel: 0860 102 312 / Email: chronicmedicine@universal.co.za

24-hour EmergencyTel: 084 124

claims@universal.co.za

Grintek Electronics Medical Aid SchemeTel: 011 591 8207 / E-mail: gemas@universal.co.za

Websitewww.gemas.co.za

Council for Medical SchemesTel: 0861 123 267 / E-mail: complaints@medicalschemes.com

Web: www.medicalschemes.com

Fraud hotlineFax: 011 807 6165