Join the medical Scheme that understands the needs of the South African family.

Who is GEMS

Who can join GEMS

10 Reasons to join GEMS

The Government Employees Medical Scheme (GEMS) is a restricted medical scheme providing accessible, affordable and rich benefits to qualifying Public Service employees and their nominated beneficiaries. GEMS currently provides quality healthcare to over 720 000 members and 1.8 million beneficiaries.

Choose GEMS today as your medical scheme of choice and receive healthcare benefits that will give you peace of mind!

*Rule 6 of the Scheme Rules explains who can become a GEMS member. The Public Service Act is available on the Department of Public Service and Administration website at www.dpsa.gov.za.

REMEMBER: You cannot be a member or a registered dependant of more than one medical scheme at the same time.

GEMS is specifically designed to offer the following qualifying Public Service employees affordable and accessible healthcare:

• A National Department listed in Schedule 1 of the Public Service Act.

• A Provincial Department listed in Schedule 2 of the Public Service Act.

• A Provincial Administration listed in Schedule 2 of the Public Service Act.

• Organisational components listed in Schedule 3 of the Public Service Act.

• Any employer group approved by the Scheme (a list of these employers is available in Annexure A of the Scheme Rules).

1. Lower contributions vs. open and closed schemes

2. Contributions based on income

3. Up to 100% subsidy for level 1 – 5s (terms and conditions may apply)

4. Low co-payment levels

5. Broadest definition of beneficiaries – up to 5 generations can be covered!

6. No late joiner penalties

7. Primary Care Extender benefit – provides an additional R750 per year for the Emerald and Emerald Value options. This benefit is available for:

• Network general practitioner consultations;• Acute prescribed medicine obtained at a network

pharmacy; and• Pathology tests performed at a preferred pathology

laboratory.

It is automatically activated once the standard benefits for these services have run out.

8. Largest HIV DMP

9. Close collaboration with Trade Unions and government stakeholders

10. GEMS provides greater access to quality healthcare through a wide array of networks.

In 2020 GEMS contribution increases are among the lowest in the industry!

GEMS is a scheme that understands the needs of the South African family

better than any other!

Unfortunately, there are Public Service departments that cannot join the Scheme and these include:

• Uniformed members of The South African National Defence Force (SANDF).

• The National Intelligence Agency (NIA).• The South African Secret Service (SASS).• Uniformed members of the South African Police

Service (SAPS).• Any department where the conditions of service do not

allow you to join GEMS.

This is an entry-level benefit option, tailored for Level 1 - 5 employees, subject to Network Family Practitioner Nomination and Specialist Referral Rules.

• Low cost: up to 100% employer subsidy• Comprehensive In-Hospital benefits for healthcare

services rendered in and by public and private hospitals on the GEMS Network

• No co-payments at GEMS network providers or use of GEMS formulary medicine

• Comprehensive Out-of-Hospital benefits for healthcare services, which are typically rendered by healthcare providers on the GEMS Network

This is a mid-level benefit option, tailored for members with limited to average healthcare needs.

• Comprehensive In-Hospital benefits for healthcare services rendered in and by public and private hospitals,

• Comprehensive Out-of-Hospital benefits for healthcare services, which are typically rendered by healthcare providers that are not on the GEMS Network, subject to Specialist Referral Rules.

• Personal Medical Savings Account (PMSA) and Block Benefit from which some In- and Out-of-Hospital healthcare services are funded.

This is a high-level benefit option, tailored for members with average to above-average healthcare needs.

• Comprehensive In-Hospital benefits for healthcare services rendered in and by public and private hospitals

• Comprehensive Out-of-Hospital benefits for healthcare services, which are typically rendered by healthcare providers that are not on the GEMS Network.

This is an entry-level benefit option, tailored for members with limited healthcare needs.

• Offers members comprehensive In-Hospital benefits for healthcare services rendered in and by public and private hospitals,

• Comprehensive Out-of-Hospital benefits for healthcare services, which are typically rendered by healthcare providers on the GEMS Network, subject to Specialist Referral Rules.

This is a high-level benefit option, tailored for members with average to above-average healthcare needs.

• Comprehensive In-Hospital benefits for healthcare services rendered in and by public and private hospitals on the GEMS Network

• Comprehensive Out-of-Hospital benefits for healthcare services, which are typically rendered by healthcare providers on the GEMS Network, subject to Network Family Practitioner Nomination and Specialist Referral Rules.

This is a high-level benefit option, tailored for members with above-average to extensive healthcare needs.

• Comprehensive In-Hospital benefits for healthcare services rendered in and by public and private hospitals

• Comprehensive Out-of-Hospital benefits for healthcare services, which are typically rendered by healthcare providers that are not on the GEMS Network.

TANZANITE ONE EMERALD VALUE

BERYL EMERALD

RUBY ONYX

You can choose one of six options,based on you and your family’s needs.

What makes GEMS different from other Schemes – a financial perspective

Did you know that, as a Public Service employee, you may qualify for a subsidy from your employer when you join GEMS which could result in further savings to your pocket?

A subsidy is an amount your employer pays towards the cost of GEMS. If you qualify for a subsidy, your employer will pay a portion of your contribution each month and you will pay the rest. The amount depends on the size of your family. Your HR practitioner can help you better understand how you qualify for a subsidy.

The tables below show the full contributions for the year and do not include any subsidies, which you may qualify for. If you qualify for a subsidy**, your employer will pay part of the contribution and you will be required to pay the balance.

TANZANITE ONE

R0 - R9 728.00 1 116 882 480

R9 728.01 - R13 651.00 1 169 936 517

R13 651.01 - R23 386.00 1 243 984 549

R23 386.01 + 1 455 1 231 696

BERYL

R0 - R9 728.00 1 235 1 231 692

R9 728.01 - R13 651.00 1 339 1 329 764

R13 651.01 - R23 386.00 1 462 1 462 821

R23 386.01 + 1 755 1 755 996

RUBY

R0 - R14 650.00 2 550 1 915 990

R14 650.01 - R25 301.00 2 840 2 135 1 105

R25 301.01 + 3 150 2 370 1 220Please note: 20% of contributions on the Ruby Option will go towards the Personal Medical Savings Account.

EMERALD VALUE

R0 - R14 650.00 2 434 1 859 905

R14 650.01 - R25 301.00 2 694 2 087 1 015

R25 301.01 + 3 018 2 320 1 130

EMERALD

R0 - R14 650.00 2 852 2 172 1 059

R14 650.01 - R25 301.00 3 157 2 440 1 187

R25 301.01 + 3 539 2 713 1 323

ONYX

R0 - R14 650.00 4 875 3 733 1 466

R14 650.01 - R31 216.00 5 074 3 863 1 592

R31 216.01 + 5 478 4 211 1 776

Total contribution is based

on the current family size and

salary information provided.

Subsidy contribution portion: these

figures are only a guide, member

to contact his/her HR office to

confirm subsidy receivable.

Kindly note that GEMS does not

determine the subsidy as the subsidy

is determined solely by the employer.

Introducing the Evolution

SAPPHIRE HAS EXPERIENCED AN EVOLUTION! TO BECOME AN OPTION THAT SYMBOLIZES POWER, TRANSFORMATION AND GROWTH… SAPPHIRE IS NOW TANZANITE ONE!

The evolution brings with it:

• Comprehensive cover for both in-hospital and out-of-hospital benefits.

• All level 1 – 5 members will continue to enjoy up to 100% subsidy from their employer. This means you could be getting so much more without paying a single cent!

• Coordinated care. You will now have a dedicated GP with access to a network of private hospitals - irrespective of the admission type.

• With amongst the lowest monthly contribution increase of all our options at only 7.19% - it only makes sense for you to stay on the EVO!

• It is the option that minimizes your exposure to out-of-pocket payments.

• The Out-of-Hospital Primary Care Extender Benefit provides an additional R750 per beneficiary per year for the Emerald and Emerald Value options.

This benefit is available for:

1. network general practitioner consultations;2. acute prescribed medicine obtained at a network

pharmacy; and3. pathology tests performed at a preferred pathology

laboratory.This benefit will be automatically activated once the standard benefits for these services have run out.

• Full Access to a Network of Private Hospitals• Unlimited GP and Specialist consultations - must

adhere to care coordination rules• Overall In-Hospital Benefit limit of R250 000 per family,

subject to the use of a State or GEMS Network Facilities• Access to Over-the-Counter (OTC) medicine - limited to

R95 per beneficiary per event and R263 per beneficiary per year

What do you get on Tanzanite One?

Emerald Value option healthier outcomes for you and your family!

EVO is the best performing option on GEMS!

It is easy to get the most out of our Network options by adhering to the

principles of coordinated care!

1 Nominate a GP on the GEMS Network. Your dependants are also able to nominate their own GP – it’s flexible!

IMPORTANT TO REMEMBER!

Don’t visit a non-nominated GP, or you’ll have to make a 30% out-of-pocket payment.

2 Specialist referral

The Specialist Referral rule for Tanzanite One and EVO requires that beneficiaries request pre-authorisation by submitting a fully completed request form when the referral is from a non-nominated provider, before authorisation can be provided.

3 Visiting the hospital

From time to time, we all may have to go to the hospital. As EVO members, your family must use a hospital on the GEMS network. There are a number of network hospitals to choose from (you can find the full list on the GEMS website at www.gems.gov.za).If you don’t have a GEMS Network hospital within 50km of your place of residence in an emergency, don’t stress. You can still use the nearest hospital.

Members on EVO automatically save 14.7% from the traditional Emerald option.

IMPORTANT NOTE

When you can use a non-network hospital:

• You’re on a trip and there’s no network hospital nearby;

• In case of a medical emergency;OR

• The specialised care you need isn’t available at the nearest network hospital.

Use of non-network hospitals may result in a co-payment of up to R12 000 per admission.

Postal addressGEMS, Private BagX782, Cape Town, 8000

GEMS Emergency Services0800 444 367

GEMS Fraud hotline0800 212 202

GEMS Fraud emailgems@thehotline.co.za

Disease Management

Programmes that look after you and your family’s wellbeing.

1. You will receive healthcare support and advice, provided by the GEMS Personal Healthcare support team and qualified nurses, who will help you better manage your health and chronic condition.

2. Added support in your relationship with your doctor and the care you receive from him/her.

3. Assistance with following the treatment prescribed for your condition.

What are the benefits of being on a care or disease management programme?

What care and disease management programmes does GEMS offer?

• Chronic medicine management• Dental management• Emergency services• Managing HIV/AIDS• Maternity Programme• Oncology management• Optometry management• Prescribed Minimum Benefits

GEMS Contact Centre0860 00 4367

Fax0861 00 4367

Webwww.gems.gov.za

Emailenquiries@gems.gov.za

The digital card is available on the GEMS Member app and is convenient for members and their beneficiaries. Make use of the

multi-function GEMS Member App to interact with the Scheme at home or on the go to make your life easier. Use the QR code

to download the GEMS Member App.

Contact details

OUT-OF-HOSPITAL BENEFITS

EVOThis is an efficiency discounted option based on Emerald. Members pay discounted membership fees in exchange for adhering to care coordination rules

(family practitioner nomination and specialist referral) and are required to use the Scheme’s hospital network.

Personal Medical Savings Account (PMSA)

Audiology, occupational therapy and speech therapy

Limited to R3 825/family and R1 914/beneficiary/year

Block benefit (day-to-day benefit) Limited to R9 762/family/year and R4 879/beneficiary/year. Subject to GP nomination and specialist referral rules

Chronic Back and Neck Rehabilitation Programme

Subject to registration on Chronic Back and Neck Rehabilitation Programme

Circumcision Global limit of R1 576/beneficiery

Dental services (conservative, dentistry including acute medicine)

Limited to R5 454/beneficiary/year

Emergency assistance (road and air)

General Practitioner (GP) and Specialist services

Shared limit with day-to-day block benefit.Subject to GP Nomination of Network GP, Specialistreferral and use of Network Hospital

GP network extender benefit 2 additional consultation at network GP once block benefit is exhausted. For beneficiaries with chronic conditions registered on the disease management programme

HIV infection, AIDS and related illness Subject to registration on the HIV Disease Management Programme

Infertility

Maternity (ante- and post-natal care) Subject to Maternity Programme Protocols

Medical and surgical appliances and prostheses

Limited to R44 364/family/year

Mental health (Consultations, assessments, treatment and/or counselling by GP, Psychiatrist, Psychologist)

Limited to R19 559/family/year

Optical services (eye examinations, frames, lenses, permanent or disposable contact lenses and acute medicine)

Limit of R2 450/family/financial year

Other Professional Health Services (Dieticians, Podiatrists, Social Workers, Registered Counsellors and Orthoptists)

Pathology and Medical Technologists Subject to Block benefit and GP nomination and Specialist referral rules

Physiotherapy Limited to R2 423/beneficiary and R4 846/family/year. Shared with day-to-day block benefit limit

Prescribed medicine and injection material

Preventative care services

Primary care extender R750 additional benefit/beneficiary/year once the block benefit or specific sub-limits are exhausted. Shared limit with GP services, pathology, medicaltechnology and prescribed medication

Screening services

100% of cost, subject to PMB legislation Subject to annual hospital limit Unlimited, refer to Scheme rules Subject to referral by network GP

100% Scheme rates apply Subject to managed care rulesLimited to PMBsAvailable Not-Available Subject to the use of a Designated Service Providers

Pre-authorisation is neededSubject to the service being related to admissions under the annual hospital benefitSubject to other sub-limits, refer to the GEMS Rules

IN-HOSPITAL BENEFITS

Prescribed minimum benefits (PMBs)

Annual hospital benefit (public and private hospitals, registered unattached theatres, day clinics and psychiatric facilities)

Alcohol and drug dependencies

Allied health services Limited to R1 682/family/year

Alternatives to hospitalisation (sub-acute hospitals and private nursing)

Blood transfusion

Dental services (conservative, restorative and specialised)

Shared limit with out-of-hospital benefit ofR5 454/beneficiary/year

Emergency services (casualty department)

General Practitioner (GP) and Specialist services

Oncology (chemo and radiotherapy) Limited to R391 188/family/year

Organ and tissue transplants Limited to R651 975/beneficiary/year

Other Professional Health Services (Dieticians, Podiatrists, Social Workers, Registered Counsellors and Orthoptists)

Pathology and Medical Technology

Physiotherapy Limited to R5 275/beneficiary/year

Medical and surgical appliances and prostheses

Limited to R44 364/family/year

Mental health Limited to R19 559/family/year

Radiology (advanced) R23 469/family/year

Radiology (basic)

Renal dialysis Limited to R279 412/family/year

Surgical procedures (including maxillofacial surgery)

Radiology (advanced) Limited to R23 469/family/year

Radiology (basic) Limited to R3 896/Beneficiary and R7 140/family

Renal dialysis If a non-network provider is voluntarily used, a co-payment of 30% will be applied per event

OUT-OF-HOSPITAL BENEFITS

100% of cost, subject to PMB legislation Subject to annual hospital limit Unlimited, refer to Scheme rules Subject to referral by network GP

100% Scheme rates apply Subject to managed care rulesLimited to PMBsAvailable Not-Available Subject to the use of a Designated Service Providers

Pre-authorisation is neededSubject to the service being related to admissions under the annual hospital benefitSubject to other sub-limits, refer to the GEMS Rules