GEMS Emerald Value Option 2017

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GEMS EMERALD VALUE OPTION 2017

 

Dear Healthcare Provider

GEMS new Emerald Value Option for 2017

The South African healthcare industry is undergoing many significant changes and developments towards

Universal coverage and other regulatory changes. Within this changing environment, GEMS is well equipped

to continue to deliver services that provide our members’ with significant value.

In an effort to further increase value and improve the quality of care and service convenience GEMS is

pleased to announce their new GEMS Emerald Value option which comes in to effect from 01 January 2017

(subject to approval by the Council for Medical Schemes).

This option is an affordable alternate to the current Emerald plan with a similar benefit structure which

offers the member value at a more affordable premium. The GEMS Emerald Value option pivots on a network

driven plan and includes a list of network hospitals where cover is provided in full subject to member benefits and scheme rules.

Care coordination is therefore key to the success of the GEMS Emerald Value option and when in need of treatment and/or possible referral to a Specialist, the member will be required to

* visit their nominated network Family Practitioner (FP), and if required,

* obtain a referral to a network Specialist

Should a member not adhere to the referral process and hospital network requirement with the exception of emergencies, co-payments will apply as follows,

* 30% copayment on the FP and Specialist account.

* Up to R10 000 hospital co-payment when not admitted to a network hospital

Dental and Optical visits on this option will also be subject to Network Providers.

A list of network Hospitals & Providers can be found on the GEMS website; www.gems.gov.za , members may also contact GEMS on; Enquiries@gems.gov.za or 0860 00 4367 or GEMS, Private Bag X782, Cape Town, 8000.

Kind regards

GEMS Network Management

29 December 2016

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A new option, called the “GEMS Emerald Value Option”, is to be introduced by GEMS in 2017. This option, will allow members who are on the Emerald option to opt for the “Value Option” of which the benefit will be a zero increase in contributions for 2017 in exchange for the following limitations:
• Every family member covered by GEMS to choose a family practitioner, with the allowance of consulting another GP when far from the chosen family practitioner, e.g. holiday
• Referral to a Specialist (excluding emergencies) only through the family practitioner
• Only utilisation of hospitals on a GEMS hospital network (excluding emergencies)

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The new GEMS Emerald Value option, which includes a hospital network, offers the same rich benefits as the existing Emerald option, but at a more affordable rate.

Important things about the GEMS Emerald Value option

  • You must nominate a General Practitioner, who must be on the GEMS Network, as your first-line when seeking medical care and who you will consult for all your doctor visits. A 30% co-payment will apply to all GP claims received from a non-nominated GP.
  • You must use a hospital, of your choice, from the GEMS Emerald Value Hospital Network for your in-hospital needs. View the GEMS Emerald Value Hospital Network list for the list hospitals.
  • Specialist referral must be obtained from your nominated GP for all specialist requirements.
  • Provision is made in the event that you may require healthcare while travelling, or require specialised care that may not be available through your nominated healthcare providers, to ensure that your needs are taken care of. As part of this, you are allocated three visits to a non-nominated GP per family per year for emergencies only, i.e. in cases where you cannot get to your nominated GP.

Did you know?

Members who stay on Emerald face contribution increases of 15% for 2017, while members who switch from Emerald to the new GEMS Emerald Value will have lower increases – as low as 0%* – after their medical subsidy is included. *Please note: Depending on the number of dependents, most Emerald members will experience a 0% increase and even a decrease in the actual out-of-pocket amount they pay. Please consult your HR on what your subsidy entitlements are.

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