Gems Medical Aid, the second largest health medical aid scheme in South Africa, is a beacon of reliability. It consistently delivers quality coverage for healthcare services, including addiction treatment coverage, ensuring your peace of mind.

With Gems Medical Aid, you can rest assured that your inpatient treatment for substance use disorders is covered comprehensively for up to 21 days, including a 3-day medically supervised detoxification per year. This coverage runs from January to January, providing you with year-round support.

Their comprehensive coverage and varying plans make it accessible to individuals from different income brackets. While treatment for substance use disorders may be accessible through all their plans, members will still be liable to limitations and benefit caps.

We aim to make the transitionary phase into treatment smooth and hassle-free at We Do Recover. This informative article will discuss everything you need to know about GEMS Medical Aid Plans.

Overview Of Gems Medical Aid

Gems Medical Aid offers members comprehensive plans that cover addiction treatment therapies. Their plan’s benefits will vary in coverage depending on the plan chosen by the member. 

In the following subsections, we will discuss in-depth what these benefits, limitations and exclusions will entail.

Gems Plans And Benefits

Gems offers six plans to their members: Tanzanite One, Beryl, Ruby, Emerald Value, Emerald and Onyx, with pricing beginning at R1,363 per month.

Eligibility Criteria

To be eligible to join Gems Medical Aid, one must be a government employee or a nominated beneficiary of a government employee. Members can enrol their dependants, including their spouses, children or life partners.

Substance Use Disorder Treatment Coverage

Gems Medical Aid offers extensive coverage for treating substance misuse in South Africa. 

Extent Of Coverage For 

Members of Gems Medical Aid will receive up to 21 days of residential inpatient rehab treatment, including a 3-day medically supervised detoxification. This coverage is inclusive of drug and alcohol addiction.

This medical aid also covers certain outpatient treatment services and individual counselling sessions. The extent to which outpatient services and the number of individual counselling sessions a member will receive coverage for will be determined by the plan type the member is enrolled in – the more comprehensive the plan, the more benefits the member will access.

Additionally, Gems Medical Aid provides partial coverage for group therapy sessions.

Limitations And Exclusions

Gems Medical Aid has limitations and exclusions for substance abuse treatment coverage and therapies.

Some of these limitations and exclusions include:

• Pre-authorisation requirements for inpatient rehab.
• Limitations on the number of individual counselling sessions and outpatient services.
• Exclusions for specific addictions. For example, process addictions like gambling and porn.
• Exclusions for coverage to alternative therapies that are not deemed medically necessary.
• Treatment for substance use disorders that are outside of South Africa.

Process For Coverage

A pre-authorisation procedure must be followed to receive coverage by Gems Medical Aid. 

The Pre-Authorisation Process

Before seeking treatment for a substance use disorder, it is imperative to follow a pre-authorisation process to be approved; without approval, members will not receive coverage and will be liable to pay for the entirety of their stay.

At We Do Recover, we will phone Gems on your behalf and provide them with the ICD-10 codes of your addiction and our facility’s practice numbers. A letter of motivation from a healthcare professional is not necessary to be admitted.

Claims Process

Members can claim their substance abuse rehabilitation treatment through a straightforward process that looks like this:

• Submit their claims to Gems with supporting documentation; these documents include invoices and treatment plans provided by the facility.
• Once Gems receives the claim, it will undergo review.
• The member will be reimbursed for the amount claimed if the claim has been approved.

Conclusion

Gems Medical Aid aims to provide its members with quality and extensive coverage for substance use disorders. To ensure this, they offer a variety of plans to suit different income brackets. To be a member of Gems Medical Aid, individuals need to be government employees.

Members can expect to receive coverage for up to 21 days of inpatient rehab, including a 3-day medically supervised detoxification. Their benefits, limitations, and exclusions will vary depending on the plan they are enrolled in, so it is crucial that they carefully review their plans to determine the extent to which they are covered.

At We Do Recover, we have partnered with Gems Medical Aid to ensure their members receive high-quality treatment for their addictions. Call us today at 081-444-7000 to start your pre-authorisation process.

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