As per communique from GEMS (SAPPHIRE & BERYL) 2016 Tariffs
- 3. Tariff changes for 2016Please be advised of the following changes for 2016:
- An increase of 5.5% in professional fees for doctors participating in the GEMS FP network. Kindly note that with effect from 1 January 2016, the following fees and tariffs will be applicable to Sapphire and Beryl network doctors:
Level Dispensing doctor tariff Non-dispensing doctor tariff Authorisation Level 1 R332.50 R250.50 After 6th visit within network Level 2 R319.10 R250.50 After 6th visit within network Level 3 R290.80 R232.90 After 6th visit within network
2019 Discovery Health Medical Aid Fees
Date: 7 November 2019
Discovery Health Medical Scheme is the largest open medical scheme in South Africa, covering nearly 2.8 million beneficiaries at 31 December 2017, and with an open medical scheme market share of approximately 56%.
According to Discovery, it estimates total medical inflation for 2018 at between 11.2% and 12.2%, with the variance due to utilisation trends in different health plan options.
However, risk management by Discovery Health and the ongoing positive impact of the Vitality wellness programme on members’ health, will reduce medical inflation by 2%, resulting in contribution increases that are within the corridor of 3% to 4% above CPI after allowing for the required adjustment for VAT,” it said.
With CPI sitting at 5.1% in July, a CPI + 4% increase puts the industry range at 9.1%.
The new prices for all 27 of Discovery’s plans for 2019 are detailed in the tables below, along with how much they have increased.
The tables show the total contribution (including for medical saving, where applicable) for the main member.
The KeyCare Plus ranges have changed from R0 to R12,200 and R12,201+, to R0 to R13,050 and R13,051+, while the Access product has been dropped and a Start product has been added.
Therefore no price increases are shown below, just the new fees for 2019.
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Medical Aid Industry to Collapse?
BHF head warns on SA medical aid sector
PUBLISHED: 28 OCTOBER 2015
The medical aid industry is in trouble, and if nothing is done, it will collapse, forcing millions of members to turn to the public healthcare sector, warns a leading medical executive. The industry has been paying out more than it collects from members. And, on top of that, contributions have been increasing at a pace that is 50% higher than the inflation rate, while benefits have been shrinking.
City Press reports that it is this lethal combination that makes the CEO of the Board of Healthcare Funders, Humphrey Zokufa, believe that medical aid schemes are at risk of collapsing. “What we are seeing right now is that schemes are paying out more than they collect per annum. Some schemes are even using their reserves to pay for claims. “This is not an ideal situation and it is not sustainable in the long term,” said Zokufa.
The Board of Healthcare Funders represents the interests of 65% of the country’s medical aid schemes, but works with most of them in one way or another. Zokufa explained that when schemes paid out more than they collected, premiums were bound to go up. “This is what we have been seeing in the past couple of years, with schemes increasing their premiums far higher than the inflation rate. Medical schemes are trying to match what they pay out. The downside to this is that when premiums increase, it’s the members who suffer,” he said.
Elsabé Conradie, GM of stakeholder relations at the Council for Medical Schemes, agreed, saying that members were the ones who bore the burden of hefty annual increases. She explained that the reason medical aid premiums were escalating every year was primarily because of the high prices charged by service providers, mainly specialists. She also cited the decline in the number of young, healthy people signing up for medical aid schemes. This group usually cross-subsidises the old and sick members of a medical aid scheme.
Zokufa also pinned the blame on specialists and private hospitals, as both were claiming exorbitant amounts from medical aids. “Specialists and private hospitals have free rein in this country. They charge whatever they want because their prices are not regulated,” he said. “When you look at private healthcare expenditure in the last 10 years, you will see that 60% of the budget goes to specialists and private hospitals, while general practitioners and other entities share the remainder of the pie. This situation is not healthy or adequate because it fuels the contribution increases and impacts on the money paid by members to cover the shortfall on their medical bills,” he said.
Should GEMS Patients be Treated With Circumspection?
GEMS MEMBERS TO FEEL THE PAIN
Unlike other medical schemes, it has never made use of the underwriting provisions in the Medical Schemes Act designed to protect schemes from “anti-selection”, a phenomenon in which people only join up when they get sick or anticipate big health bills.
The Act allows schemes to impose a late joiner penalty on people who have never previously belonged to medical schemes, a three-month waiting period in which the new member pays contributions but cannot claim, as well as a 12 month-exclusion on pre-existing medical conditions.
GEMS principal officer Guni Goolab is quoted in the report as saying that beneficiaries who entered and left GEMS in the same year had triple the hospital admission rate of other members.
There were 8,591 such beneficiaries last year, who had a hospital admission rate of 72%: they contributed R30m yet claimed R149m from the scheme, he said.
Discovery Health, one of SA’s biggest medical scheme administrators, said in the report it too was concerned about an increase in hospital admissions, particularly in regions where new hospitals had opened.
Noach said in the report that Discovery Health and its biggest client Discovery Health Medical Scheme had recently met doctors and private hospitals to make them aware of their concerns.
Neither GEMS nor the Council of Medical Schemes are willing or able to dispel the rumours that it is in financial difficulty , writes Bronwyn Nortje in Business Day.
Nortje writes that along with very real concerns around the financial health of the scheme and the effect of higher contribution increases and benefit changes on its members, GEMS’ persistently low solvency issue also raises questions about the conduct of the council.
“This raises the question why other large schemes, such as Discovery, are forced to adhere to the requirements of the Medical Schemes Act, while Gems is given endless extensions.
“Despite at the time having a solvency ratio of twice what Gems currently has, the registrar for medical schemes rejected Discovery’s plan to restore its solvency levels and told the scheme to shape up or ship out.
Medical Schemes or Aids administered by Universal Healthcare Administrators
|AECI MEDICAL AID SOCIETY VALUE OPTION|
|BCIMA (BUILDING AND CONSTRUCTION INDUSTRY MEDICAL AID FUND)|
|COMPCARE MEDICAL SCHEME|
|GRINTEK ELECTRONICS MEDICAL AID SCHEME|
|MASSMART HEALTH PLAN|
|NBCRFLI WELLNESS FUND HEALTH PLAN|
|TIGER BRANDS MEDICAL SCHEME|
|TRANSMED STATE PLUS NETWORK OPTION|
|UMVUZO HEALTH STANDARD AND ULTRA OPTION|
|UNIVERSAL HEALTH WORKERS PLAN|