Workshop Programme Part 1: Background Part 2: Benefits and Contributions Part 3: Scheme Operations...

Workshop Programme

Part 1: Background

Part 2: Benefits and Contributions

Part 3: Scheme Operations

Part 4: GEMS Features

Part 5: Communication Strategy

Part 1 - Background

Introduction

• Questions, rumours, comments

• Today:

– What is GEMS?

– What GEMS offers?

– Who can join?

– Why should employees join?

– What we need from you?

Overall Objective

“The state, as an employer, seeks to ensure that there is adequate provisioning of healthcare coverage to public service

employees that it is efficient, cost-effective and equitable; and to provide further options for those who wish to

purchase more extensive cover”

Part One - Background

Introduction

• Questions, rumours, comments

• Today:

– What is GEMS?– What GEMS offers?– Who can join?– Why should employees join?– What we need from you?

Environment

• Current subsidy: 2/3rds of contributions to R1014

– 39% of employees (380 000) do not access the subsidy

– 550 000 employees do access the subsidy

– 44% of covered employees are at the Rand cap

• Employees enrolled on 68 medical schemes

– Over R5,2 billion per annum

– 91% of covered employees on 15 medical schemes

– Almost 50% on Bonitas, Polmed and Medshield

• High medical inflation

• Lack of employer control

• Affordability is key

Affordability: Coverage by Salary

Access to Medical Subsidy by Salary Notch

0%

20%

40%

60%

80%

100%

0 1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 16

Salary Level

% A

cces

sin

g M

edic

al S

ub

sidy

Yes

No

Research Process

• 2000 – Define problem and develop outline of possible

solutions • 2001

– Investigate the accreditation of a limited number of schemes

• 2003 – Investigate the feasibility of a restricted membership

medical scheme for public service employees and the option of scheme accreditation

• 2004 – Further research on feasibility– Scheme business plan

• Administrative ease

– Single scheme approach even more efficient

• Open schemes fee structure:

– Broker commissions

– Higher administration fees

• Absent Employer influence

– Product development and costing

• No universal coverage attained

• Cost implications

Open Scheme Accreditation

Mandate and Policy Process

• 1999 Remuneration Policy Review

• PSCBC Resolution 7 of 2000

• Cabinet approval July 2002

• PSCBC Resolution 2 of 2004

• Cabinet approval 3 November 2004

• Cabinet approval 25 May 2005

• Cabinet approval 14 September 2005

GEMS

• Registered on 1 January 2005

– Board of Trustees – Principal Officer – Scheme executive– Multiple administrators– Comprehensive managed care– HIV Disease management

• Establish operations during 2005

• Active member enrolment 1 January 2006

Strategic Focus

• Understanding employee needs

• Establish competitive scheme

• Ensure sustainability

• Encourage primary health care

• Incorporate innovation

• Ensure efficiencies

• Eliminate wastage and inefficiencies

• Promote BBBEE

• Effective information management

Member Enrolment

• Access

• Affordability

• Preserve integrity of GEMS benefits and contributions

– Critical mass of members and clear time-frames

• Social Partners

– Valued participation

• Alternative options considered:

– Income bands

– Coverage

– Departmental

Member Enrolment

2006 • New appointees access subsidy only on GEMS• Voluntary for existing employees and pensioners • Consider scheme amalgamations

2007 • As for 2006

2008 • As for 2006• Feasibility study to assess making enrolment of GEMS mandatory and the findings of

this study presented to Cabinet

2009 • Mandatory enrolment for access to subsidy• Transfer of all remaining pensioners • Consider scheme amalgamations

2010 • Mandatory coverage for all employees

Member Enrolment

• Benefits

– Critical mass of members identified

– Incremental growth

– Operational and financial risk reduced

– Mandatory enrolment delayed

• Concerns

– Reserve transfer

– Voluntary enrolment

Member Enrolment

• Progress

– Numerous meetings with labour

– Collective bargaining still underway

– Draft resolution tabled at PSCBC

• Implementation of GEMS is continuing

Summary

• Interesting programme

• Special treats

• Great information to be shared

• Enjoy

Questions?

Part Two - Benefits and Contributions

2005 vs. 2006

• Competitiveness

• Changes to variable MSA

• Changes to treatment of ARB

• CMS comments - Ruby option

Options 2006

Sapphire– Lowest cost, basic entry level option for new members

– Public hospitals only

– PMBs unlimited, other hospital events R100 000 family limit

– Out-of-hospital: Basic primary care at PrimeCure network

• GP’s, medication, basic dentistry, basic radiology and

pathology

• Treatment protocols

– Chronic meds: PMBs only

– No optical benefit

– HIV/AIDS benefit programme

Scheme Benefits

Scheme Contributions

  TOTAL

Salary Band Member Adult Child

0 - 2 500 327 240 138

2 501 - 4 000 351 258 147

4 001 - 6 000 369 270 153

6 001 + 444 324 186

Sapphire

Beryl– Low cost, entry level option for new members

– Network of private hospitals

– PMBs unlimited, other hospital events R500 000 family limit

– Out-of-hospital: Basic primary care at PrimeCure network

• GP’s, medication, basic dentistry, basic radiology and pathology

• Treatment protocols

– Chronic meds: PMBs only

– Optical benefit included

– HIV/AIDS benefit programme

Scheme Benefits

Scheme Contributions

Beryl

TOTAL

Salary Band Member Adult Child

0 - 2 500 372 372 210

2 501 - 4 000 399 399 228

4 001 - 6 000 438 438 249

6 001 + 525 525 300

Ruby– Mid-range option for healthy members

– All private hospitals

– All hospital events unlimited

– Out-of-hospital: 25% Personal Savings Account

• GP’s, medication, dentistry, radiology and

pathology, optical

• Free choice of provider

– Chronic meds: PMBs only

– Comprehensive HIV/AIDS cover

Scheme Benefits

Scheme Contributions

Ruby

RISK SAVINGS TOTAL

Salary Band P A C P A C P A C

0 – 4 000 525 366 198 174 123 66 699 489 264

4 001 – 6 000 564 393 213 189 132 72 753 525 285

6 001 – 8 000 621 435 234 207 144 78 828 579 312

8 001 + 684 477 258 228 159 87 912 636 345

Emerald

– Comprehensive cover for families and chronic members– All private hospitals– All hospital events unlimited– Out-of-hospital cover:

• Block benefit limit: R3000 per beneficiary/ R6000 per family

• Covers Specialists, basic radiology, pathology & physiotherapy

• Individual benefit limits: GPs, dentistry, medicines, scans & optical

– Chronic meds: R6000 per beneficiary and R12 000 per family

– Comprehensive HIV/AIDS cover

Scheme Benefits

Scheme Contributions

Emerald

TOTAL

Salary Band Member Adult Child

0 – 6 000 738 528 285

6 001 - 8 000 816 585 315

8 001 + 897 642 348

Onyx– Comprehensive cover with high limits for families and

chronic members– All private hospitals– All hospital events unlimited– Out-of-hospital cover:

• Block benefit limit: R5000 per beneficiary/ R10 000 per family

• Covers Specialists, basic radiology, pathology & physiotherapy

• Individual benefit limits: GPs, dentistry, medicines, scans & optical

– Chronic meds: R10 000 per beneficiary and R20 000 per family

– Comprehensive HIV/AIDS cover

Scheme Benefits

Scheme Contributions

Onyx

TOTAL

Salary Band Member Adult Child

0 – 6 000 1023 735 348

6 001 – 10 000 1101 789 375

10 001 + 1185 849 405

Competitiveness of GEMS

GEMS vs Market

0

500

1000

1500

2000

2500

3000

3500

4000

4500

5000

60% 65% 70% 75% 80% 85% 90% 95%Richness

Con

trib

utio

n (P

AC

)

Market Line Medicover Alta + 0% Savings Gems Onyx + 0% Savings (R 0 - R 6,000)Gems Onyx + 0% Savings (R 6,001 - R 10,000) Gems Onyx + 0% Savings (R 10,001 +) Spectramed SpectraPlus + 0% Savings (4001+)Fedhealth Ultima 300 + OHEB_15% Savings Discovery Ess Comp + 25% savings Spectramed Elite + 0% Savings (4200-11000)Medshield MediElite + 0% Savings Bonitas Elite + 0% Savings Medshield MediBonus + 0% SavingsMedicover Titan + 21% Savings Medihelp Dimension Elite + 5% Savings Gems Emerald + 0% Savings (R 0 - R 6,000)Gems Emerald + 0% Savings (R 6,001 - R 8000) Gems Emerald + 0% Savings (R 8,001+) Medshield MediPlus + 0% SavingsOxygen Elite Plus + 11% Savings Bonitas Standard + 0% Savings Medihelp Plus + 0% SavingsResolution Prestige + 0% Savings Medshield MediBase + 0% Savings Fedhealth Ultima 200 + OHEB_15% SavingsDiscovery Ess Priority + 25% savings Gems Ruby + 25% Savings (R 8,001+) Gems Ruby + 25% Savings (R 6,001 - R 8,000)Oxygen Advanced + 10% Savings Gems Ruby + 25% Savings (R 4,001 - R 6,000) Medihelp Dimension Prime 3 + 10% SavingsGems Ruby + 25% Savings (R 0 - R 4,000) Medicover Bona Plus + 15% Savings Discovery Ess Saver + 25% savingsMedicover Bona + 0% Savings Oxygen Standard Plus + 13% Savings Resolution Progressive + 8% SavingsBonitas Bonsave + 25% Savings Spectramed Alliance + 0% Savings (5001-10000) Bonitas Primary + 0% SavingsMedshield MediValue + 0% Savings Medihelp Dimension Prime 2 + 25% Savings Fedhealth Maxima Standard + 18% SavingsFedhealth Maxima Plus + 25% Savings

Part Three - Scheme Operations

GEMS Operations

• Why GEMS will be a winner

• What happens behind the scenes?

– Registration process

– Claims management

– Customer services

• What can you expect immediately?

• Some fun for today

A winning team behind GEMS

• GEMS has selected “best of breed” partners to provide

services to members:

– Metropolitan Health Group – administration

– Solutio – managed care services and HIV

programme

– PrimeCure – primary care and hospital services for

two options

• We all work together to offer a unique service to GEMS

members

A winning team behind GEMS

• Metropolitan Health Group:

– 18 large medical schemes (e.g. Polmed, Bankmed,

Transmed)

– Interface with Persal for > 150,000 families

– Our systems and people rated annually

– Etc etc

• So, what will we do for you……

Questions?

Part Four - GEMS Features

Why GEMS ?

• Government single largest contributor to health spend

• Government largest employer

• Represent 28% of open scheme membership

• Benefits designed specifically for you

• 380 000 uncovered – due to affordability

• Employees represented in GEMS

• Extensive scientific research undertaken

• Principles - Equity, Affordability and access to

comprehensive cover for all

• For you by you

The real facts about GEMS

• GEMS separately registered legal entity

• Governed by Medical Schemes Act

• Scheme registered 1 January 2005

• Enrolment of new members starts 1 January 2006

• Supported by Government agencies

(Persal,GCIS)

• Both private and public hospitals

• Scheme - no past legacy

• We request your assistance

Who may join?

• Only public service employees appointed in:

– National Departments

– Provincial Administrations

– Provincial Departments

– Organisational Components

• Listed in schedules 1, 2, and 3 of the Public Service Act

but excluding the SANDF, National Intelligence and South

African Secret Service

• Fixed term contract employees and other temporary

employees appointed for less than 12 months are not

eligible

• Existing pensioners are eligible

Key Differentiators

• Easy to understand benefit structures

• Competitive rates and benefits

• Competitive service fees

• Income based rate tables

• Entry level and comprehensive options

• Both low cost options offer unlimited primary care

• Non health care costs of the lowest in Industry

• No levies, no co-payments

• Includes chronic medicine & other disease and management programmes

• GEMS designed just for you

Other benefits

• Subsidy available for all eligible persons

• Comprehensive HIV/Aids program

• Individuals free to select level of cover

– 5 Options

• Automatic acceptance (no special entry criteria)

• Traditional healers benefit??????

Other features

• GEMS actuarially sound

• Governance in accordance with best practice

• Contributions will be used for member benefits

• Improve health of employees

• Favourable prospective member profile

• Carefully selected service providers

• Potential size of GEMS

• Positive spin-offs for health sector

We need your support• Enormity of the task – impossible without committed

support within all structures• Help us by assisting colleagues

– Inform colleagues of facts – Sources of Information – Procedures– Forms

• We commit to provide the necessary tools – CD’S – Marketing brochure– Posters– Videos– Website– Cassette tapes in various languages

GEMS marketing actions

• Champions workshop

• National & Provincial road shows

• Prepare Persal staff and ensure system readiness

• Regular communication newsletters, e-mails, website

& messages via Persal

• Use Human resource staff, communicators, salary and

others to promote GEMS

Enrolment process

• Members responsible to notify existing scheme of

cancellation of membership

• Members to select appropriate cover

• Application and other forms available on website

• Register dependants

• Complete all required forms: chronic and HIV

• Follow HR procedures

Where do I obtain more information?

• Go to www.gems.gov.za

• Call 0860 00GEMS (4367)

• E-mail enquiries@gems.gov.za

Questions?