workshop programme
DESCRIPTION
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? - PowerPoint PPT PresentationTRANSCRIPT
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Workshop Programme
Part 1: Background
Part 2: Benefits and Contributions
Part 3: Scheme Operations
Part 4: GEMS Features
Part 5: Communication Strategy
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Part 1 - Background
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Introduction
• Questions, rumours, comments
• Today:
– What is GEMS?
– What GEMS offers?
– Who can join?
– Why should employees join?
– What we need from you?
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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”
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Part One - Background
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Introduction
• Questions, rumours, comments
• Today:
– What is GEMS?– What GEMS offers?– Who can join?– Why should employees join?– What we need from you?
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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
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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
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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
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• 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
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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
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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
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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
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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
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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
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Member Enrolment
• Benefits
– Critical mass of members identified
– Incremental growth
– Operational and financial risk reduced
– Mandatory enrolment delayed
• Concerns
– Reserve transfer
– Voluntary enrolment
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Member Enrolment
• Progress
– Numerous meetings with labour
– Collective bargaining still underway
– Draft resolution tabled at PSCBC
• Implementation of GEMS is continuing
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Summary
• Interesting programme
• Special treats
• Great information to be shared
• Enjoy
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Questions?
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Part Two - Benefits and Contributions
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2005 vs. 2006
• Competitiveness
• Changes to variable MSA
• Changes to treatment of ARB
• CMS comments - Ruby option
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Options 2006
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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
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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
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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
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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
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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
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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
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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
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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
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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
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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
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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
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Part Three - Scheme Operations
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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
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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
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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……
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Questions?
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Part Four - GEMS Features
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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
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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
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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
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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
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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??????
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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
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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
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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
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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
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Where do I obtain more information?
• Go to www.gems.gov.za
• Call 0860 00GEMS (4367)
• E-mail [email protected]
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Questions?