Overview

BMW Employees Medical Aid Society believes members and doctors need to be free to choose the rate of payment for medical services. When billed using the Society Rate, BEMAS repays claims directly to the healthcare professional. The member gets direct payment for claims billed higher than the Society Rate. You can then settle the claim with the doctor.

We constantly engage with the relevant representative bodies to look at ways of enhancing professional relationships to the benefit of both parties. We look to do this without compromising our principles.

The healthcare funding industry needs to carefully balance the needs of all the key roles players - namely healthcare professionals, members and the Society.

The Society participates in the Discovery Health GP and Premier Rate Specialist Direct Payment Arrangements. You can benefit by using healthcare professionals participating in the payment arrangements because the Society will cover their approved procedures in full (within the available limits of your relevant benefits). These providers will not charge you for services provided and claims will be paid directly to the providers, which will be convenient you.

Healthcare professionals who participate in the payment arrangements are also the Designated Service Providers ("DSP") for Prescribed Minimum Benefits, and payment will be made as stated. However, if you choose not to use the DSPs, the Society will continue to cover the cost of your treatment by such practitioners at up to 100% of the Society Rate.

Click here for your in-hospital guide.

Click here for your out-of-hospital guide

General practitioners (GP)

A general practitioner (GP) is a medical practitioner who gives primary care and specialises in family medicine. A general practitioner treats acute and chronic illnesses and provides preventive care and health education for all. They have particular skills in treating people with multiple health issues.

If you consult with your GP out-of-hospital

We pay for GP consultations from your available day-to-day benefits and cover in hospital consultations from your Hospital Benefit. If your GP participates in the Discovery Health GP Network, he or she will be covered in full, both in- and out-of-hospital (subject to funds available and applicable limits).

Medical specialists

A specialty in medicine is a branch of medical science. After completing medical school, physicians or surgeons usually add to their medical education in a specific specialty of medicine by completing a multiple year residency. Medical practitioners who take on a medical specialty are known as medical specialists.

We pay for out-of-hospital specialist consultations from your available day-to-day benefits, and cover in hospital consultations from your Hospital Benefit. If your specialist participates in the Discovery Health payment arrangement, he or she will be covered in full, both in- and out-of-hospital (subject to funds available and applicable limits).

Dentists

Dentistry is the known evaluation, diagnosis, prevention, and treatment of diseases, disorders and conditions of the oral cavity and maxillo-facial area. This includes the adjacent and associated structures and their impact on the human body.

How we cover dentistry

We pay dentistry done out-of-hospital from your day-to-day benefits, depending on available funds in your available dentistry limit up to a maximum of the Society Rate.

Approved, defined major maxillo-facial surgery is paid from the Hospital Benefit up to a maximum of the Society Rate and isn't limited to the dentistry limit.

X-rays

X-rays are photographs or examinations of body parts made by electromagnetic radiation.

How we pay for x-rays depends on whether you have the x-ray performed in- or out-of-hospital.

X-rays done in-hospital

We pay for the x-ray from the Hospital Benefit up to a maximum of the Society Rate as long as it is related to your confirmed hospital admission.

X-rays done out-of-hospital

We will pay these claims from your day-to-day benefits, as long as you have money available up to a maximum of the Society Rate.

MRI and CT Scans

Who may refer you either for a MRI or CT scan

Please note

• All MRI and CT scans must be referred by a specialist.
• We will only approve scans that have been referred by an appropriate specialist. We will fund MRI or CT scans appropriately referred by a GP during an emergency hospital admission from the Hospital Benefit, depending on benefit confirmation.

How we pay MRI and CT scans needed before planned surgery

If an MRI or CT scan is done as part of a pre-operative work-up for a planned surgical procedure, in other words the scan can be performed before the admission. We will pay the MRI or CT scan as an out-of-hospital scan.

How we pay MRI and CT scans needed for conservative back and neck treatment

If the MRI or CT scan is needed during an approved admission for a chronic back or neck condition, we will pay the MRI or CT scan as an out-of-hospital scan.

In-hospital

We pay approved MRI and CT scans performed during an approved hospital admission from the Hospital Benefit as long as the scan is related to the reason for the admission.

Out-of-hospital

We pay the account from your overall annual limit, up to an annual limit per family each year.

Other scans

Mammograms

A mammogram is an x-ray examination of the female breast. It uses low-energy x-rays to visualise fine details of breast tissue, particularly the presence of calcification or soft tissue masses. This allows for early diagnosis of breast cancer.

Mammograms done out-of-hospital

We will pay for one mammogram annually from your Screening and Prevention Benefit.

Pregnancy scans

Ultrasound imaging allows imaging of the interior of the human body. Images that can't be seen by x-rays are visible through ultrasound imaging.

A maximum of two 2D scans are covered during the pregnancy. if you need more scans, you need to send us a motivation from your doctor. If you have a 3D or 4D scan, it will only be paid up to the cost of a 2D scan.

We will pay these claims from your day to day benefits and Maternity Benefit limit, subject to pre-authorisation/registration of your pregnancy.

Blood tests

A blood test is any test designed to discover abnormalities in a sample of a person's blood, such as the presence of alcohol, drugs or bacteria or to determine the blood group.

Please note

The Society does not cover some blood tests (such as the ALCAT test).

The way we pay for blood tests depends on whether you have the blood test done in- or out-of-hospital.

Blood tests done in-hospital

We pay for the blood tests from the Hospital Benefit up to a maximum of the Society Rate as long as it is related to your confirmed hospital admission.

Blood tests done out-of-hospital

We will pay these claims from your day-to-day benefits, as long as you have money available.

Endoscopies

What are endoscopies?

Endoscopies - also called scopes - are used to investigate certain medical and surgical conditions such as gastric ulcers, reflux and infections. When we refer to endoscopies and how we cover them, we only refer to four diagnostic endoscopies which include gastroscopy, colonoscopy, sigmoidoscopy and proctoscopy. These are all used to investigate the digestive system. Scopes may also be used to investigate other body systems. All such endoscopies fall outside of this benefit.

Cover for gastroscopy, colonoscopy, sigmoidoscopy and proctoscopy.

Please note

• Please call us to confirm your benefits at least 48 hours before having this procedure.
• Where the scope is performed in your doctor's rooms we refer to this as "out-of-hospital"
• Where the scope is performed in a hospital, payment for this healthcare service is based on your Plan benefits

In-hospital

In-hospital with authorisation

Hospital and related accounts paid from the Hospital Benefit

In-hospital without authorisation

Scope codes and all other related accounts will be paid from your available day-to-day benefits, depending on available funds.

Out-of-hospital

In doctor's rooms with authorisation

Scope codes and all related accounts will be paid from overall annual limit.

Other (allied healthcare professionals)

Allied healthcare professionals are clinical healthcare professionals other than medicine, dentistry, and nursing. They work in a healthcare team to make the healthcare system function.

In-hospital treatment

We pay up to 100% of the Society Rate, limited to your overall annual limit if you confirmed your admission.

Out-of-hospital treatment

We pay 80 % of the Society Rate from your available day-to-day benefits as long as you have money available.

Cover for planned hospital admissions

We cover you for planned hospital admissions. Please call us 48 hours before you go to hospital to confirm your admission.

How we pay the hospital account

We pay the hospital account (the ward and theatre fees) in full at the rate agreed with the hospital. You have cover for a general ward, not a private ward.

How we cover your healthcare professionals

Your doctor or treating healthcare professional's accounts are separate from the hospital account and are called related accounts. Examples of related accounts include the doctor, anaesthetist and any approved healthcare expenses, (for example, radiology or pathology), that you are billed for during your hospital stay. These expenses are funded from the overall annual limit. Please contact us to pre-authorise your benefits before you receive treatment or extend your hospital stay.

The services performed by selected providers while you are in hospital, will be covered up to a maximum of 150% of the Society Rate. In other words, an amount of up to 50% over the Society Rate will automatically be paid for services you receive in hospital. This applies to GPs, medical specialists, maxilla-facial surgeons, physiotherapists, radiologists and pathologists.

Healthcare professionals are free to set their own rates.

If your healthcare professional charges the Society Rate, we will pay him or her directly. If your healthcare professional charges more than the Society Rate, we will pay you. You will have to make sure you pay your healthcare professional's the full amount.

If your healthcare professional participates in the Discovery Health network, he or she will be covered in full. You can find a healthcare professional who participates in the Discovery Health payment arrangement by logging in.

Limits, clinical guidelines and policies apply to some healthcare services and procedures in hospital.

Medicine to take home from hospital (TTO)

Medicine on discharge (TTO), is included on the hospital account if it is obtained on the date of discharge. Alternatively it is limited to the Day-to-Day benefit and applicable limits.

Before you go to hospital for any planned procedure, you must:

• See your doctor
• Call us on 0860 002 107 to confirm your hospital admission at least 48 hours before you go to hospital. If you do not confirm your admission, you will be responsible for the payment of all accounts.

When you contact us, give us the following details:

• Your membership number
• When you will be admitted into hospital
• The date of the procedure
• The name and practice number of the hospital or clinic
• Your treating doctor's name and practice number
• Your diagnosis (ask your doctor for the ICD-10 diagnosis code)
• The procedure name and code (ask your doctor for RPL procedure codes)
• If one of your dependants is admitted, give us their details

Cover will apply based on our rules

We pay medically appropriate claims. Your cover will apply based on our Society Rules, funding guidelines and clinical rules. There are some expenses that you may be responsible to pay while you are in hospital that your benefit does not cover, for example, private ward costs. Certain procedures, medicine or new technologies need separate confirmation while you are in hospital.

Cover for Prescribed Minimum Benefits

For Prescribed Minimum Benefits, we pay hospital admissions for defined conditions in full at our designated service providers.

How we cover your childbirth

We cover childbirth from your Hospital Benefit, including home births done by midwives with valid practice numbers and who are appropriately registered with the Board of Healthcare Funders. You must authorise the childbirth admission to hospital or home birth with us before you go to hospital. Remember to register your baby with us as soon as possible so we can cover your baby.

There are certain limits for childbirth benefits:

Childbirth service	Limit
Pregnancy scans	Two 2D ultrasound scans for each pregnancy, which we pay from the available money in your day-to-day benefits and Maternity Benefit limit
Normal vaginal deliveries	A stay of three days and two nights in hospital
Caesarean section	A stay of four days and three nights in hospital