Gems tweaks its benefits
MEDICAL SCHEME: IMPROVES SOLVENCY RATIO
Principal officer says in past two to three years, it worked hard to strengthen scheme’s financial position.
The Government Employees Medical Scheme (Gems) contracted roughly 1 800 private sector specialists towards ensuring benefits last longer. After months of complaints by teacher unions, Gems revealed it will enhance benefits by 5.4% across all benefit options in 2019.
Earlier this year, the National Association of Professional Teachers of SA (Naptosa) was one of three teacher unions that publicly called out Gems for delayed payments, resulting in forced out-of-pocket payments and a high incidence of benefits running out before year end.
Principal officer Dr Guni Goolab said after extensive engagement with stakeholders – including unions – through the year, changes in 2019 for members on the following options will include:
Sapphire option: Increased access to private hospital care at network healthcare facilities for selected procedures, including circumcision and children’s tonsil removal; cataract and retinal procedures; elderly hip and knee replacements; certain gynaecological and obstetrics procedures, including childbirth; and hospitalisation for certain mental health conditions. Members will also have a family planning benefit of R2 822 per year starting in 2019; Emerald and Emerald Value options:
An out-of-hospital primary care extender benefit on selected options. This provides an extra cushion of R500 per beneficiary per year so members can access healthcare if their benefits for general practitioner services, prescribed medicine and pathology tests run out before year end; and
Ruby option: An extra R500 per year per family to extend their current out-of-hospital block benefit if this benefit limit is depleted.
The Emerald Value option follows accepted practice in the UK, Canada and Australia, with a model where members nominate a general practitioner (GP) of their choice and only consult a specialist if referred by their designated GP.
“Obviously, if the member is diagnosed with a condition that requires ongoing specialist care, they do not have to consult with their GP for each visit,” says Goolab.
Using this option means there are fewer specialist consultations, which often carry high copayments for scheme members.
Gaylin Bowles of Naptosa confirms the association has been in consultations with Gems during the past few months.
Scheme to reach targeted solvency ratio
In addition to improving benefits next year, Gems is confident it will be able to reach government’s requirement of a 25% solvency ratio in 2019, three years ahead of schedule and for the first time since inception. The solvency ratio in 2017 was 15.2%.
Goolab says the scheme had been working over the past two to three years to strengthen its financial position and is confident of improving its solvency ratio and ability to increase benefit limits.
A medical scheme’s solvency ratio refers to its accumulated cash reserves in relation to received contributions. Schemes with a lower solvency ratio will have a reduced claims-paying ability compared with those with a higher solvency ratio.
The 7.1% average contribution increase falls at the lower end of increases in the medical schemes industry.