Did you know?
- That GEMS is the largest restricted medical scheme in South Africa
- That they are also the second biggest medical scheme in South Africa
I can already hear you saying; “Ja, but that means nothing because the government is behind them, and in any case, it’s only for government employees.”
I’d love to agree with you but listen to this:
For every R100 in member contributions, GEMS spends R95 on healthcare costs, compared to the industry average of R91.
Now if that’s true, and I have no reason to doubt them since they advertise it, then it ain’t bad at all, is it?
Of course, we could argue that R95 spent on healthcare means nothing. It’s quite possible that the other medical schemes have negotiated better rates from healthcare providers in order to come in at R91. But this is a competitive industry so I doubt it.
So here’s why GEMS makes sense:
- You could get up to 75% of your payment as an employer subsidy.
- Or what if you’ve never been on a medical scheme before? Every time you’ve tried to join, they’ve applied late joiner penalties. None of that applies at GEMS if it’s the first time ever that you’re joining a medical aid, and you couldn’t previously afford medical cover.
- Or what if you wanted to add parents, nephews and nieces? Many schemes won’t allow this. At GEMS, if they’re financially dependent on you, then why not?
- Or what if you were told that waiting periods would be applied. At GEMS, if you’re a first-time medical aid joiner, then that’s just a rumour.
So how does GEMS work?
It’s all based on income bands:
- Those who earn the least, pay the least, BUT
- everyone on the same plan enjoys the same level of benefits
GEMS has very cleverly named their plans after gemstones.
Traditionally they offer five different plans ranging from the highest level of benefits – and highest cost – to the lowest level of benefits – and lowest cost:
- Beryl, and
But in 2017 GEMS decided to do something different
They’ve split the Emerald option in two:
- Emerald, and
- Emerald Value
Here – in a nutshell – is how they work.
Both Emerald options allow unlimited hospital benefits every year. This means you can book into a private hospital and know your stay is fully covered. So here we’re talking about things like theatre fees, medicines, materials, and hospital equipment all being unlimited.
However, the difference is:
- The Emerald option allows you to book in at any hospital you wish to, while
- The Emerald Value option means you must use a hospital in the GEMS network. If you decide not to use one of the hospitals in the network, then a R10,000 co-payment is required from you.
When it comes to specialists:
- On the Emerald option, you can see any specialist you wish to
- On the Emerald Value option, your GP needs to refer you to a specialist and you must use a network provider.
Specialists who have an agreement with GEMS are paid at 130% of the GEMS rate while specialists who aren’t in the network are paid at 100%.
GEMS does not offer a personal medical savings account (PMSA) on either of these plans.
Day-to-day benefits (GEMS calls these ‘block benefits’) are limited to R4,175 per member on both plans, and a total of R8,353 per annum for everyone on that plan.
So what happens if you’re on a disease management programme, and you’ve used up your R4,175 benefit?
GEMS will allow one additional visit at a network GP once your block benefit is exhausted.
The difference between the two plans comes in here:
- The Emerald option allows you to visit a GP of your choice while
- The Emerald Value option requires you to use a nominated GP from the GEMS list. If you see someone who is not your nominated GP, then a 30% co-payment applies.
Of course, the Emerald option is the better of the two, but here’s the kicker
It’s the difference in price which makes the Emerald Value so valuable.
Here’s how the two stack up:
- Those earning between R0 to R11 892 monthly income band
|Principal Member||R2 295||R2 066||R229|
|Per Adult Dependant||R1 664||R1 498||R166|
|Per Child Dependant||R 841||R 757||R 84|
|Total cost Family of 3||R4 800||R4 321||R479|
- Those earning between R11 892.01 to R20 538 monthly income band
|Principal Member||R2 541||R2 287||R254|
|Per Adult Dependant||R1 869||R1 682||R187|
|Per Child Dependant||R 943||R 849||R 94|
|Total cost Family of 3||R5 353||R4 818||R535|
- Those earning R20 538.01 and higher monthly income band
|Principal Member||R2 848||R2 563||R285|
|Per Adult Dependant||R2 078||R1 870||R208|
|Per Child Dependant||R1 051||R 946||R105|
|Total cost Family of 3||R5 977||R5 379||R598|
To sum it all up
The GEMS Emerald Value option means you must use one of the GEMS networked hospitals. If you decide not to, then you’ll end up with a R10,000 penalty.
The specialist you see while in hospital needs to be referred to you by your nominated GP.
I had a look at the list of hospitals and there’s a list as long as your arm – everything from Clinix (6 hospitals) to Life Healthcare (65 hospitals/clinics) to Netcare (56 hospitals/clinics) to Medicross (13 clinics) to NHN (21 hospitals).
For day-to-day GP visits and the like, you need to use your nominated GP. Using anyone else will mean a 30% co-payment
But it’s the monthly savings which makes it all worthwhile. Look at the tables above and you’ll see, on average, a R500 cost saving each and every month.
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