Employees of the state will have to pay on average 7.7% more in contributions to the Government Employees Medical Scheme (Gems) from next year, but lower earners will benefit from almost unlimited access to private hospitals on the lowest option. 

The increases which will impact members range from 7.19% of the Emerald Value Option to as high as 8.7% on the comprehensive Onyx option. 

They are, however, among the lowest increases that large medical schemes have announced for next year: Discovery Health’s average increase is 9.5%, Bonitas’s 9.9%, Momentum Health’s 8.2% and Fedhealth’s is 10.6%.  

Dr Stanley Moloabi, the scheme’s chief operating officer, told a recent stakeholder briefing on the benefit and contribution changes for next year, that the scheme found its options are between 9% and 36% cheaper than similar options on other schemes. 

Government employees enjoy good subsidies for their membership of the scheme and those earning between R8,500 and R17,000 a month may qualify for a 100% subsidy of their contributions if they opt for the lowest-cost option for a limited number of dependants. This Sapphire option will be renamed Tanzanite One from next year and will offer private hospital cover for admissions. 

Last year, the scheme increased its cover on this option to include 20 types of admissions to private hospitals. As of next year all admissions types will be covered, although Dr Vuyo Gqola, the scheme’s chief healthcare officer, says there are limits. The cover does, however, extend beyond prescribed minimum benefit cover, she says.

Contributions for members who will be moved from the Sapphire to the Tanzanite option will increase by about 12%, Moloabi, says. Most members will, however, be shielded from this increase because of the subsidy they enjoy from the government. 

The cost to the scheme of providing these private hospital benefits is R576 million, but Moloabi says the scheme is sure it can sustain these benefits and is also enhancing benefits for other members.

Karyna Pierce, the schemes chief financial officer, also told the briefing that the scheme has now managed to save the required reserves – schemes are obliged to keep 25% of annual contributions in reserve to ensure the scheme can survive periods of high claims. The Gems achieved a reserve level of 26.8% of its contributions in September, she says. 

Pierce says the introduction of waiting periods when members add new beneficiaries to prevent members adding beneficiaries only when they are in need of health services saved the scheme R0.95 billion in 2018. 

The scheme also saved R211m by reviewing its treatment protocols, she says. These and other interventions have enabled the scheme to enhance benefits in total by around R1bn by, for example, covering more chronic diseases, enhancing screening benefits, reducing co-payments, ensuring benefits last longer during the year and extending private hospital cover on the low-cost option.

The scheme has also achieved significant savings on its Emerald Value option on which members are obliged to use a single GP, only consult a specialist when referred to one by that GP and to use hospitals with whom the scheme has contracted. Members on the Tanzanite One option will also have similar rules to contain the costs. 

Members on the middle-of-the-range Emerald option can save up to 25% of their contributions after the subsidy if they agree to limit their choice of doctors and hospitals and move from the Emerald option to the Emerald Value option, the scheme says. 

Moloabi says the scheme members are covered for more GP and nurse consultations than members of other schemes and the scheme is better at paying PMBs than its competitors. 

He also believes the scheme is not compromising the quality of healthcare as the scheme has scored well on healthcare outcomes measures. 

He admits that the scheme is still struggling with its call centre and says Gems hopes more members will use its digital channels. Many calls relate to benefits as members do not always understand how their benefits work.