Gems on road to recovery

Gems members will have expanded coverage./ 123RF
Gems members will have expanded coverage./ 123RF

The Government Employees Medical Scheme's (Gems') measures aimed at containing costs were paying off, enabling the scheme to keep contribution increases low and expand benefits, the scheme announced this week.

In addition, the scheme expects to meet its reserve requirements earlier than expected, which will enable Gems to keep the lid on contributions or enhance benefits further in the future.

Next year, members will pay 7.1% more on average in contributions, but the increases on the different options range from 4.3% on the Emerald Value option to 9.8% on the comprehensive Onyx option.

This compares favourably with the increases announced by the country's other large medical schemes, Momentum at 10.7%, Discovery Health at 9.2%, Bonitas and Bestmed at 8.9% and Fedhealth at 8.5%.

Dr Stan Moloabi, COO for Gems, says though negotiations with the public sector bargaining forum are still in progress, the increase in the subsidy government employees enjoy for membership of Gems is likely to be higher than the increase in contributions on most options, and especially on the Emerald Value option.

This option has the same benefits as those on the popular Emerald option but members choose a single general practitioner, can only see a specialist when referred to one by a GP and can only use certain hospitals that have contracted with Gems.

Moloabi said there were now 178000 members on this option and members can save 16% in contributions by switching from Emerald to Emerald Value and possibly as much as 25% once the subsidy is applied.

Members of the lowest-cost option, Sapphire, can enjoy a 100% subsidy if they are in one of the five lowest government employee income bands, earning less than about R16 000 a month.

Moloabi also announced that from next year, Sapphire members and their dependants will have access to private hospitals and doctors for unlimited GP consultations, circumcisions, removal of tonsils and adenoids in children, cataract and retinal procedures, hip and knee replacements, certain gynaecological and obstetric procedures and certain mental health conditions.

Benefits for family planning and over-the-counter medicines on the Sapphire and next level up option, Beryl, are also being enhanced next year.

Moloabi said an additional R500 per beneficiary per year would be added to the benefit that extends access to GPs, medicines at pharmacy networks and pathology tests for members of the Ruby, Emerald and Emerald Value options when they have exhausted their medical savings accounts.

Currently, 11% of members on the Ruby option exhaust their medical savings accounts before year end. This is expected to decrease to 1% with the enhanced benefit, Moloabi said. In total, the scheme will spend R832m in additional benefits next year, he said.

Schemes are required by law to keep 25% of contributions in reserve to enable them to pay your claims through times when members are claiming a lot.

Gems was supposed to build its reserves up to this level within five years of its launch in 2006, but struggled to do so as a result of rapid membership growth, which set its reserve target higher each year.

After a year of high claims in 2016, the schemes reserves declined instead of increasing to just less than 7% of contribution income.

However, new measures to combat fraud and manage claims, as well as waiting periods to prevent beneficiaries joining the scheme only when they are sick, have turned the scheme around.

The scheme now expects to end this year with reserves in excess of 18% and to end next year with the required 25% - three years ahead of the target date for reaching this level of reserves set in its agreement with the Council for Medical Schemes.

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