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Employee Presentation
2011
By Ouma Mogashoa
AGENDA
Eligibility
Subsidy
Benefits Structure
GEMS Network Providers
Friends of GEMS
HIV/AIDS programme
Chronic Medication
Maternity programme
Emergency Services
Contributions
Fraud
Eligibility
Public Servants only
Spouse
Biological / adopted/foster children to age 21 , to age 27
if still studying
Grand children
Siblings
Parents and parents in laws
Grand parents and grand parents in laws
Subsidy as from 1 March 2010
Subsidy on GEMS only
All new employees appointed after 01/07/2006
Employees who had not made use of the subsidy in June 2006
GEMS subsidy is 75% of contributions up to R720 / R1440 / R1880 /
R2320 / R2760 (maximum of R2760)
o Depending on the number of registered dependants
Special dispensation for salary levels 1 to 5: 100% subsidy on the Sapphire
Option
Contract employees who are paid 37% of basic salary in
lieu of employee benefits:
o No additional subsidy
Middle and Senior Management:
o Salary structuring rules and value of salary package
are unchanged
GEMS Benefit Options for 2011
SAPPHIRE
• All limits were increased by 5%
• All Lowest cost, basic cover & access to Public Hospital
• Primary care at a GEMS network Provider
GP’s, medication
Basic dentistry, basic radiology and pathology
Enhanced Optical benefit with limit of R2 888 per family every second year
Unlimited access – no co-payments
Subject to Scheme’s protocols
• Chronic medicine for 26 listed conditions including comprehensive HIV/AIDS cover
• Medipost as Chronic DSP
• Hospital benefits at public hospital facilities with overall limit of R140 070 per family
• Private hospital maternity benefit & Maternity Programme
• 5 antenatal visits per pregnancy and 2x 2D SCANS
• Out of Hospital – Mental Health includes psychologist
GEMS Benefit Options for 2011
BERYL
• All limits were increased by 5%
• All Lowest cost, basic cover & access to Public Hospital
• Primary care at a GEMS network Provider
GP’s, medication
Basic dentistry, basic radiology and pathology
Enhanced Optical benefit with limit of R2 888 per family every second year
Unlimited access – no co-payments
Subject to Scheme’s protocols
• Chronic medicine for 26 listed conditions including comprehensive HIV/AIDS cover
• Medipost as Chronic DSP
• Hospital benefits at public hospital facilities with overall limit of R140 070 per family
• Private hospital maternity benefit & Maternity Programme
• 5 antenatal visits per pregnancy and 2x 2D SCANS
• Out of Hospital – Mental Health includes psychologist
GEMS Benefit Options for 2011
RUBY
• All limits increased by 5%
• Savings plan option for healthy members
• Day-to-Day Block Limit R1 124 per family when PMSA is exhausted
• 25% of contributions go to a Personal Savings Account
• Personal Savings Account:
Covers day to day medical costs
GP’s, medication, dentistry, radiology, pathology, optical, physiotherapy
Contraceptives
• Medipost as courier pharmacy for Chronic Medication
• Home Birth benefit R6 610 per beneficiary
• Maternity Programme (5 antenatal visits per pregnancy and 2x 2D SCANS)
• Comprehensive HIV/AIDS cover & Medication at Medipost
• Access to all private hospitals with unlimited cover
• Preventative Care paid from Risk fund(Pap Smear, Cholesterol test, Mammogram, Glaucoma
screening)
• Appliance Limit at R47 250 per family over 2 calendar years (phased out)
GEMS Benefit Options for 2011
EMERALD
• All limits increased by 5%
• Comprehensive cover for bigger families and chronic members
• Caregiver Block benefit of R2 961 per beneficiary limited R5 922 per family
Cover Specialists, General Practitioners, Physiotherapy & Maternity
• Supportive block benefit of R7 350 limited to 2 calendar years (Phased out)
• Home Birth Benefit R6 941 per beneficiary & Maternity Programme paid from risk
• Separate benefit limits
Basic radiology (R4 725 per beneficiary), specialised dentistry (R6 615 per beneficiary over 24 months), medication (R7 119 per family), advanced radiology (R14 238 per family), optical (R3 150 per beneficiary) allied health services (R2 100per family), Basic Dentistry sub-limit of (R3 150 per beneficiary), physiotherapy (R5 768 per family) and pathology (R5 786 per family) phased out.
• Chronic medicine & Comprehensive HIV/AIDS cover
R7 119 per beneficiary limited to R14 333 per family
• Breast Reduction – Pre-authorisation required
• All private hospitals & All hospital events unlimited
• Contraceptive benefit subject to R1800 acute sublimit
GEMS Benefit Options for 2011
ONXY
• All limits increased by 5%
• Comprehensive cover with high limits for families and chronic members
• Block benefit: R6 227 per beneficiary limited R12 453 per family
Covers basic radiology & pathology
Allied Health, General Practitioner, Specialist, Physiotherapy & Maternity
• Separate benefit limits
Specialised Dentistry (R10 962 per family), Medication(R11 204 per family), Optical (R3 728 per family)
• Chronic meds & Comprehensive HIV/AIDS cover
R12 155 per beneficiary limited to R24 917 per family p.a.
• Contraceptive Benefit R2 258 (oral and injectable only)
• All private hospitals & All hospital events unlimited
• Advanced Radiology with a limit of R17 7980
• Home Birth Benefit R6 914 per beneficiary & Maternity Programme paid from risk
• Breast Reduction benefit – pre-authorisation required
• Appliance benefit limit of R60 900 per family over 2 years (phased out)
The Gems network
Our healthcare service provider networks
includes GP’s, pharmacies, dentists,
optometrists
A network healthcare providers will display
a GEMS Network logo in their practice
window, making it easy for you to identify.
The friends of GEMS
Countrywide, over 10 000 healthcare service providers
such as GPs, dentists, pharmacists, physiotherapists,
speech therapists, optometrists, etc. have signed up to
become Friends of GEMS. These healthcare service
providers have agreed not to charge GEMS members
any surcharges and co-payments for services rendered.
HIV/Aids disease management programme
Benefits available: o Medication to treat HIV/AIDS (antiretroviral
therapy; mother-to-child; including treatment
for the baby)
o Medication to treat and prevent
opportunistic infections associated with
HIV/AIDS
o Pathology tests
o Assistance in finding registered counselors
o Regular monitoring of disease progression
to ensure you start treatment at the right
time and that it is effective
o Assistance in pre-authorisation of hospital
admissions.
o Multivitamins.
o On-going emotional support via Nurse-Line.
How do I apply for chronic medication?
Phone GEMS on 0860 00 4367 and ask for a chronic
medication application form or download one from
www.gems.gov.za
Your treating doctor must complete the form
A separate form should be completed for each member of
your family who needs chronic medication.
You only need to complete this form once
Ensure that your application is complete and signed by you
and your doctor
Fax the completed form and repeatable doctors prescription
to 0866 51 8009
Benefits
A GEMS pregnancy, birth and parenting
book upon registration on the programme
Maternity bag will be sent during third
trimester
Telephonic advice and support
Authorisation of your admission to the
hospital/Birthing facility of your choice
Care plan to guide your doctor in the
appropriate treatment necessary for the
duration of your pregnancy.
Services include:
Transfer by road or air to the closest, most
appropriate medical facility;
Emergency medical assistance;
Repatriation of a patient where medical
intervention is required
Dial 0800 44 4367 to contact GEMS
emergency services provider
2011 Contributions
Protecting your benefits:
The GEMS Fraud Line is managed by KPMG,
an independent firm that ensures that members
reporting fraud remain anonymous
Everyone that calls remains anonymous ,
unless they choose to be known
Hotline 0800 21 22 02
oToll free
o Available 24/7
Or e-mail: [email protected]
Prospective members joining GEMS
For more information about GEMS and how to join please
contact the GEMS Contact Centre:
Contact Centre: 0860 00 4367
Email: [email protected]
Application process when Joining GEMS
