Since the inception of GEMS in 2006, we pride ourselves in providing equitable access to affordable and comprehensive healthcare benefits to all public service employees. We cater for our members’ unique social and economic situations by using a different operational model than traditional medical schemes.
We’ve put together the following measures to ensure that our members and their families have access to comprehensive healthcare:
Over the years we’ve noticed an increasing number of members taking advantage of our favourable measures through anti-selective behaviour. This behaviour has increased our costs, leading to our members paying higher monthly contributions.
What is considered anti-selective behaviour?
Members who behave in this anti-selective manner get access to medical treatments and procedures at the expense of other members (who may have contributed to the scheme over a longer period). This kind of behaviour reduces our reserve funds to cater for the healthcare needs of our members and increases our member’s monthly contributions.
There are 8 591 members who joined and left the Scheme in 2015. Our research has shown that these members were three times more likely to go into hospital than members who had been with GEMS for more than a year. Collectively these former scheme members only paid R 30 million in contributions. However, by the time they cancelled their memberships the total value of their claims was R149 million.
This form of anti-selective behaviour is unethical and unfair to other scheme members and we are actively introducing processes to limit this kind of behaviour.
We’ve identified underwriting as one of the effective ways to reduce anti-selective behaviour.
Underwriting specific member categories
Underwriting refers to implementing a waiting period
s before a member can claim. We use a prospective client’s previous medical information to determine whether we apply a wating period before a client can join GEMS.
The GEMS board had a policy to exempt members from waiting periods in a bid to fulfil GEMS’ mission to provide equitable access to all our public service employees. The excessively high claims due to anti-selective behaviour by our members and service providers (mentioned above) hasn’t prevented our board from underwriting our member’s claims to protect the overall scheme.
GEMS will impose a three-month (general) and/or a twelve-month condition-specific waiting period from the 1st October 2016 for the following member categories:
Dependants who join GEMS on a different date from the principal member (this excludes new-born babies and newly adopted children).