After months of widely publicised complaints by teacher unions, the Government Employees Medical Scheme (Gems) this week revealed that it will be enhancing benefits by 5.4% across all benefit options in 2019.
Earlier this year, the National Association of Professional Teachers of South Africa (Naptosa) was one of three teacher unions that publicly called out the Gems for delayed payments resulting in forced out-of-pocket payments as well as a high incidence of benefits running out before year end.
Principal officer Dr Guni Goolab said that 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 the removal of tonsils for children; cataract and retinal procedures; hip and knee replacements for the elderly; certain gynaecological and obstetrics procedures, including childbirth; and hospitalisation for certain mental health conditions. Members on this benefit option will also have access to 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 will provide an extra cushion of R500 per beneficiary per year so that members can continue to access healthcare if their benefits for general practitioner services, prescribed medicine and pathology tests run out before the end of the year.
- Ruby option: an extra R500 per year per family to extend their current Out-of-Hospital Block Benefit if this benefit limit becomes depleted.
The Emerald Value option (EVO) 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 with 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 co-payments for medical scheme members. Goolab says the scheme has also contracted roughly 1 800 specialists in the private sector as a step towards reducing the instances where members are required to make co-payments and ensuring that benefits last longer.
Gaylin Bowles, deputy president of Naptosa, confirms that the union had been in consultations with the scheme during the last few months. “We are unable to comment on the Gems benefit changes at this point but we look forward to reviewing them and to further engagement with the scheme,” she says.
Scheme to reach targeted solvency ratio for the first time
In addition to improving benefits next year, the Gems is confident that it will be able to reach the government 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 stood at 15.2%.
Speaking at a presentation in Cape Town, Goolab said the scheme has been working over the last two to three years to strengthen its financial position and is now confident of improving its solvency ratio and ability to increase benefit limits. A medical scheme’s solvency ratio refers to the scheme’s accumulated cash reserves in relation to received contributions. Schemes with a lower solvency ratio will have a reduced claims-paying ability compared to those with a higher solvency ratio.
Low contribution increase
The average contribution increase of 7.1% falls at the lower end of contribution increases in the medical schemes industry:
- Momentum Health – 10.7%
- Discovery Health – 9.2%
- Fedhealth – 8.5%
- Bonitas – 8.9%
- Bestmed – 8.9%
Specific contribution increases for the different Gems options in 2019:
Sapphire – 6%
Beryl – 6.5%
Ruby – 6.8%
Emerald – 7.5%
Emerald Value – 4.3%
Onyx – 9.8%
Members have until Friday, December 7, to exercise any changes in their benefit options.