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Healthcare
Monday, March 1, 2010
Captive growth

The Government Employees Medical Scheme (GEMS) was registered on 1st January 2005, in accordance with the Medical Schemes Act 131 of 1998. The scheme reports to the Registrar of the Council for Medical Schemes and is defined as a body corporate that undertakes liability related to its members’ healthcare benefits in exchange for receiving contributions. GEMS is a separate legal entity that does not form part of any Government department or public entity.

GEMS actively started to enrol members as from January 2006. As GEMS is a restricted scheme for Government employees, only those persons employed within the public service or by employers approved as participating employers by the Board of Trustees can become members.
GEMS’ operational structure consists of a Board of Trustees that directs the scheme’s activities, a Principal Officer (CEO) who implements the directives of the Board, and a scheme executive that supports the Principal Officer in monitoring and managing the service levels and contractual obligations of outsourced services. Cabinet approved this operational structure in November 2004.
The GEMS Board of Trustees consists of 12 members, six of whom are member-elected. The other six persons were appointed by the Minister for Public Service and Administration and formed part of the Scheme’s Interim Board of Trustees (also known as the Steering Committee), which was charged with managing the affairs of the Scheme until such time as the member elected Board could take over.
GEMS offers its members five different benefit plans, namely Onyx, Ruby, Emerald, Beryl and Sapphire. These benefit plans are 10% to 25% less expensive, with similar or increased benefits, when compared to other medical schemes in the market.
Sapphire and Beryl are the entry-level options where cover is provided by designated provider networks. Sapphire was specifically designed to be inexpensive and it achieves this by providing out-of-hospital care at private facilities and in-hospital cover at public facilities. Emerald is the traditional option and has been designed to resemble the medical scheme plans that most medical scheme members are currently enrolled on. Ruby offers members a savings account for day-to-day medical expenses as well as a hospital plan. Onyx is the top of the line, comprehensive option.
GEMS has selected ‘best of breed’ healthcare partners, procured through thoroughly transparent tender processes, through whom the scheme delivers professional healthcare related services to its members.
These partners are:
• Metropolitan Health Group (MHG), which handles the scheme’s administration;
• Netcare 911, which delivers emergency medical services;
• Medscheme Health Risk Solutions, which offers managed care services inclusive of healthcare provider management;
• Medipost, which provides chronic medication services to members;
• Pinnacle Health, which handles GEMS’ telemarketing services;
• Qualsa, which provides pharmaceutical benefit management; and
• Aid for AIDS, which offers an HIV/AIDS management programme.

The GEMS pricing model is based on sound risk management principles that have carefully considered the risk profile of public service employees and makes use of conservative actuarial assumptions. Importantly, GEMS has not assumed the savings that can be realised through the use of the full collective purchasing power of public service employees. Public service employees are, furthermore, eligible for medical scheme subsidies (when joining GEMS) of 75% and, in some cases, even 100%, up to a limit of R2 319,00 depending on their income levels and family sizes.

Copyright © Insurance Times and Investments® Vol:23.3 1st March, 2010
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