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Designated Service Provider (DSP)
When you use the services of a Designated Service Provider (DSP), all claims, including Prescribed Minimum Benefits, are paid in full. This means you will not have to make out-of-pocket payments when using the services of these providers.
These Designated Service Providers are specific providers of healthcare services, for example General Practitioners and Specialists, who have agreed to provide services to TFGMAS Medical Aid Scheme members according to certain agreed rules. The Scheme pays these providers directly.
Cover for non-network providers
If a GP or specialist that is not a Designated Service Provider sees you in hospital, we will cover you up to 100% of the Scheme Rate.
If you are treated Out-of-Hospital by a non-network provider, we will cover you up to 80% of the Scheme Rate on TFGMAS Health Plus and up to 100% of the Scheme Rate on TFGMAS Health.
You may have a co-payment if your provider charges above these rates.
In certain instances you will not have to pay co-payments or deductibles
The Scheme will still pay the Prescribed Minimum Benefit claims in full if you have involuntarily obtained the services from a provider other than a Designated Service Provider, if:
- it was an emergency, for hospital admissions
- the service was not available from the Designated Service Provider or would not have been provided without unreasonable delay; or
- there was no Designated Service Provider within a reasonable distance from your place of business or residence.
The Scheme's designated service providers for the diagnosis, treatment and care costs (which may include medicine) for Prescribed Minimum Benefit (PMB) conditions are:
The Premier Specialist Network
General Practitioners' Services
The Discovery GP Network
Any pharmacy willing to charge dispensing fees at the Scheme's Medicine Rate.
Drug and alcohol rehabilitation
SANCA, Nishtara or RAMOT
Renal care, including dialysis
National Renal Care
Where the Scheme has appointed a Designated Service Provider (such as these listed above), non PMB's will only be paid in full if the services are obtained at the DSP.
General Practitioners (GP)
A general practitioner or GP is a medical practitioner who provides primary care and specialises in family medicine. A general practitioner treats acute and chronic illnesses and provides preventive care and health education. They have particular skills in treating people with multiple health issues.
On TFGMAS Health Plus any General Practitioner who participates in the Discovery GP Network is the Designated Service Provider for all GP visits. There are more than 3 000 GPs in this 'willing provider network' and you will be able to see whether your GP is participating in this network, by following this link, or find out more by calling 0860 123 077.
If you use one of these providers, you will not be liable for any co-payments as claims would be paid at the Scheme Rate, directly to the Network provider. If applicable, the specific limits in your Primary Care Benefit will apply. If you do not use the services of a Network GP, your claim will be paid at 80% of the Scheme Rate out of hospital only and we will make the payment to you. You will have to settle the full account with the GP.
On TFGMAS Health, you must select a primary and secondary GP from the KeyCare Network. If you see your chosen GP you will have unlimited consultations, but will need to call in for further authorisations from 16 visits and up.
If you are treated by a GP who is not one of your chosen GPs, these will accumulate to your 3 out of network visits and will only fund up to 100% of the scheme rate.
Each dependant is allowed to change their GP three times a year.
A specialty in medicine is a branch of medical science. After completing medical school, physicians or surgeons usually further their medical education in a specific specialty of medicine by completing a multiple year residency. Medical practitioners who engage in a medical specialty are known as medical specialists.
Any participating specialist in the Discovery Premier Rate Network is one of the Scheme's Designated Service Provider specialists on TFGMAS Health Plus. If you make use of their services for in- or out-of-hospital care, you will not have to make any 'above the Scheme Rate' co-payments as the provider will only charge at the Scheme Rate. TFGMAS Medical Aid Scheme will pay these claims in full, directly to the Specialist.
On TFGMAS Health you will need to be referred by your chosen GP to see a specialist and a Specialist authorisation must be loaded. These consultations fund up to the scheme rate.
You can make sure that you are using a Network Specialist by following this link or find out more by calling 0860 123 077.
If you do not use the services of a network specialist, you may have co-payments and will have to settle the claim in full.
Cover for Specialists, and the specific limits that may apply, is dependent on your benefit plan.
Dentistry is the evaluation, diagnosis, prevention, and treatment of diseases, disorders and conditions of the oral cavity, maxillofacial area and the adjacent and associated structures and their impact on the human body.TFGMAS Medical Aid Scheme provides cover for major trauma-related dental procedures, specialised dentistry and basic dental procedures.
Trauma-related dental procedures are for the treatment of certain severe infections, jaw-joint replacements, cancer-related and certain trauma-related surgery, cleft-lip and palate repairs and are normally performed in-hospital. These procedures require preauthorisation and are covered in full if performed by a network specialist. Cover for procedures performed by non-network specialists is at 100% of Scheme Rate, so you may incur a co-payment if your specialist is not on the network.
There is limited cover for specialised dentistry on TFGMAS Health Plus which includes:
- metal base and soft base dentures
- metal, porcelain and resin inlays
- root canal treatment
- periodontal treatment
- restorative phase of implants, inclusive of implant components
- crown and bridge work
- bleaching of root canal treated teeth and;
- orthodontic treatment.
These procedures are covered up to 100% of agreed rate if you see a specialist on our network and up to 100% of Scheme Rate if you use a non-network specialist.
On TFGMAS Health you receive cover in hospital for Severe dental and oral surgery.
The basic dentistry benefit is also limited and covers examinations, preventative dentistry; x-rays; fillings; acrylic and partial dentures and the addition of teeth to dentures and repair to dentures. These procedures are funded up to 100% of Scheme Rate on TFGMAS Health Plus and up to 100% of the Scheme Rate at a dentist in the Primary care network on TFGMAS Health. Basic dentistry in hospital on TFGMAS Health is not a covered benefit.
Allied and alternative Healthcare Professionals are clinical Healthcare Professionals other than those practicing medicine, dentistry and nursing. They work in a healthcare team to take care of all aspects of a medical condition.
Cover for Allied and Alternative Healthcare Professionals is dependent on your plan. Claims for most Allied and Alternative Healthcare Professionals are covered (both in-and out-of hospital) at 100% of the Scheme Rate, subject to the benefit sub limits.
Some of the services covered by this benefit are:
- occupational therapy
- chiropody, and
However, Homeopathy and Naturopathy is covered at 80% of the scheme or agreed rate, subject to the benefit sublimits.
Allied and alternative Healthcare Professionals are not covered on TFGMAS Health.