Part A: Emerald Value and EDO

1. What is the Emerald Value Option (EVO)?

The Emerald Value Option is a new benefit option for GEMS members. This option has the same benefit structure as the GEMS Emerald Option; however, it requires that:

• the member and dependants nominate a General Practitioner that will coordinate their care, and
• the patient must be referred by their nominated GP for consultation with Specialist Practitioner
• member and dependants utilise one of the Scheme's network hospitals in the case that hospital admission is required.

The contribution on the Emerald Value Option is more affordable than the Emerald Option *(Refer to salary band and number of dependants)

2. What is an EDO?

An EDO, Efficiency Discount Option, is a term used to describe an option that mirrors the benefits of another option but it is network driven (e.g. hospital network), and also applies care coordination principles (e.g. GP nomination and Specialist Referral). The Emerald Value Option is the new EDO for GEMS. The aim of an EDO is to improve health outcomes and ultimately reduce hospital admissions and associated costs.

3. What is the difference between the Emerald Option and the Emerald Value Option?

The Emerald Value Option has the same benefit structure as the GEMS Emerald Option; however, it requires that:

• the member and dependants nominate a General Practitioner that will coordinate their care,
• Specialist visits are referred to by the nominated General Practitioner, and
• the members and dependants utilise one of the Scheme's network hospitals in the case that hospital admission is required. 

4. What is the benefit of being on the Emerald Value Option?

The Emerald Value Option has the same benefits as the GEMS Emerald Option and aims to provide the same access to quality healthcare at a reduced contribution.

The only difference is that beneficiaries on the Emerald Value Option will nominate a GP who is a coordinator of their care, and be referred to their nominated doctor to a specialist.  The benefit is that people whose care is coordinated by one doctor are less likely to be admitted in hospitals or be exposed to duplicate and unnecessary procedures or medicine prescriptions.  In other words, there is improved quality of care and because there are no unnecessary procedures, medications and hospital admission and re-admissions, members preserve their benefits and realise the value in the lower contribution costs.

5. What is co-ordination of care?
Co-ordination of care is a system in which a team of healthcare professionals work together and encourage information sharing between the patient and the various healthcare providers. These various healthcare providers make up the patient's healthcare team i.e. General Practitioners, specialists, nurses and pharmacists. 

The nominated General Practitioner is at the heart of the co-ordination of care process.

Co-ordination of care helps to ensure that:

• there is no duplication of services or procedures such as blood tests, x-rays etc. as there is only one coordinator of care. This helps to preserve your benefits so that they are not exhausted unnecessarily,
• the treating doctor is aware of the medication the patient is taking, and
• the quality of care is improved and hospital admissions and re-admissions are reduced.

6. When will this option come into effect?

The Emerald Value Option will be available as of 1 January 2017 however if you would like to be on this option, you need to take advantage of the option selection period between 07 November and 07 December to change to the EVO and enjoy benefits from 01 January 2017.

7. When can I change to the Emerald Value Option?

The open enrolment period to the Emerald Value Option is between 07 November 2016 and 07 December 2016.

8. Can I downgrade or upgrade to EVO from other options?

Yes, eligible GEMS members and their dependants can join the Emerald Value Option from any other GEMS option subject to Scheme approved option change periods.

9. Does EVO cover all my dependants?

Yes, eligible GEMS members and their dependants that are on the Emerald Value Option will be covered as per membership and Scheme rules. Each dependant will have to nominate a General Practitioner or have one nominated on their behalf by the main member. 

10. What are my day to day benefits?

Day to day benefits on Emerald Value are capped up to R8 353 per family for the year.  Please note that each beneficiary can access up to a maximum amount of R4 175 on this benefit.  This benefit will be used to pay claims received for GP and specialist consultations, physiotherapy, audiology, occupational and speech therapy, medical technology and pathology services.

A family can use only up to a maximum amount of R4 082 (and only up to a maximum amount of R2 037 per beneficiary) on the Day to Day benefit for pathology. Claims related to maternity that are not covered as part of the maternity programme will also be covered under the Day to Day benefits.

11. In terms of contributions, what is the payment difference?

GEMS contributions are based on family size and income levels.

Benefit and contributions details can be found on the option pages.

12. What is the age limit of joining EVO?

There is no age limit of joining EVO. Eligible GEMS members and their dependants can join the Emerald Value Option, during the Scheme approved option change periods.

13. For day to day consultation, does GEMS offer an option of consulting with non-nominated network GP without paying a co-payment?

GEMS has different benefit options to cater for different members' needs and affordability. Each benefit option has different benefits and rules.

Members on the Emerald Value Option are required to consult with their nominated GP only. If an existing or future member requires an option that do not have this rule, one of the other options available should be considered.

14. Do I qualify for ex-gratia benefits should the need arise in the EVO plan?

Yes, all GEMS members irrespective of their benefit option can apply for Ex-gratia for review of exceptional circumstances.

15. Are the proposed EVO benefits standard or will they change annually?

All GEMS benefits are reviewed annually and where necessary, they are updated accordingly. However, there are some benefits which have a two or three-year cycle such as optical benefits. We announce benefit changes around November prior to the start of their applicable year.

Benefit and contributions details can be found on the GEMS website; members may also contact GEMS on; [email protected] or 0860 00 4367 or GEMS, Private Bag X782, Cape Town, 8000 or at the nearest GEMS Walk-in Centre.

16. Which members will EVO cater for?

The EVO caters for members that want access to the similar rich benefits that are offered on the existing Emerald option, but at a more affordable rate. These benefits are accessible through the utilization of various networks such as Family Practitioner/General Practitioner (FP/GP) Network, Specialist Network and Hospital Network.  Members on this option agree to use their nominated Network FP/GP as their first-line support when seeking medical care.

17. Will the Chronic Disease List and Formulary lists on EVO be the same as that of the current Emerald option?

Yes, the EVO is the same as the Emerald option with the only additional requirement being that members and their dependants visit their nominated Network Family Practitioner/General Practitioner to enable co-ordination of care, obtain specialist referral where specialist care is required and access one of the Scheme network hospitals in the event that hospitalisation is required. All other managed care interventions are similar to the ones that are on Emerald.

18. Is it possible to have a medical savings account option on EVO that can be activated if required by member?

The EVO does not have a medical savings account. Ruby is the only option with a medical savings account.

19. Will the Scheme not run on a loss for providing EVO at a reduced contribution rate compared to Emerald option while their benefits are similar?

No, the Scheme will not run at a loss. The average cost to the Scheme for a beneficiary on the Emerald Value Option will be lower due to the savings from coordination of care by the nominated Network Family Practitioner/General Practitioner, Specialist Referrals as well as the savings from the network hospitals where the Scheme is able to negotiate better rates for beneficiaries on this option.

20. Are members permitted to change from Emerald option to EVO at any given point, or are they only permitted to request this change during the option change season?

No, members can only change to EVO during the option change period as per the applicable Scheme rules.

21. Will the Emerald Value Option have a day to day block benefit

Yes, a day to day block benefit is available on the Emerald Value Option.

PART B: GEMS HOSPITAL NETWORK

1. Which hospital facilities can be used when selecting the Emerald Value Option?

The following hospital facilities can be used:

• any one of the Public Hospitals, and
• any one of the Private Hospitals, Day Clinics and Psychiatric Facilities listed in the hospital network for the Emerald Value Option.

2. What happens if I use a hospital that is not on the network while I am on the EVO option?

The following can occur:

• If an EVO member uses a non-network hospital (i.e. not included in the network hospitals on Emerald Value Option) then a co-payment of up to R10 000 will be payable, and
• this co-payment will be waived in the case of a medical emergency, but once the patient has been stabilised, the Scheme may require that the patient be transferred to a network hospital.

Members and dependants are still required to obtain authorisation for admission to a network hospital. Unauthorised admissions to a Network facility will still attract a co-payment of R1 000.

3. Will I still be required to pay the co-payment for using a non- network hospital if I am admitted for a PMB condition?

Yes, the co-payment applies to PMBs, except in emergencies.

4. What happens to my current authorisations issued for hospitals that are not on the GEMS network if I join the Emerald Value Option?

If you change to EVO with effect from 1 January 2017 but will be admitted to a hospital that is not on the GEMS network by 31/12/2016 and are discharged in 2017, no penalty will be applied.

If your current authorisation is for a date after 31 December 2016 at a hospital that is not on the network, you will be required to change the authorisation to a hospital within the network, or a penalty will apply.

5. Where can I find a list of Network Hospitals and Providers?

A list of network Hospitals and Providers can be found on the GEMS website;, members may also contact GEMS on; [email protected] or 0860 00 4367 or GEMS, Private Bag X782, Cape Town, 8000 or at the nearest GEMS Walk-in Centre.
 

Part C: General Practitioner (GP) Nomination

1. What is General Practitioner Nomination?

GEMS members and their beneficiaries will continue to be encouraged to select a preferred GEMS network GP and visit this doctor for their doctor consultations going forward. This is to encourage co-ordination of care*(explained on the next point) and reduce the incidence where members consult more than one GP.

(Note that GP Nomination claims rules will only apply to the Emerald Value Option.)

Consulting the same GP helps the doctor to develop a good understanding of the patient's health and treatment history so that they can make informed decisions about the patient's care, such as determining if they need to be referred to a Specialist. This means that the patient will receive the best possible health care from the right person, with the right skills and knowledge about their history and have better control of how their benefits are managed.

2. Why did GEMS find it necessary to implement GP nomination and Specialist Referral Management for the Emerald Value Option?

GP nomination and Specialist Referral Management creates Co-ordination of care aimed at improving the quality of healthcare and lowering overall health expenditure by bringing various healthcare providers and services together to create an integrated healthcare system. This system encourages high collaboration and information sharing between the patient and the various healthcare providers.

GEMS supports care co-ordination and considers the General Practitioner (GP) to be at the heart of this process.

By consulting one GP, it helps to ensure that this GP has the best understanding of the patient's health and treatment history and can determine whether a Specialist Referral is necessary.

3. Which members will GP nomination affect?

Members on the Emerald Value Option are required to nominate and use a nominated GP. This includes the main members and their dependants i.e. each beneficiary must select their own GP. 

Please note that nominating a GP is a pre-requisite for joining the Emerald Value Option.

4. How will GP nomination work?

GP nominations will work where:

• main members and their dependants each select their own nominated GP, and
• the nominated GP must be part of the GEMS network.

To find a GP on the network, members can refer to the GEMS website at http://www.gems.gov.za/.  Members may also contact GEMS on [email protected] or 0860 00 4367 or GEMS, Private Bag X782, Cape Town, 8000 or at the nearest GEMS Walk-in Centre.

5. What happens if a member's current GP is not on the GEMS network?

GEMS will actively assist to get the member's GP on the Network. Should their GP choose not to join the GEMS Network, the member will be notified and given the option to select a network GP of their choice.

6. Can any GEMS Network GP be nominated?

Yes, if the GP is on the GEMS GP network then they can be nominated as this means their practice number has been validated by the GEMS Network contracting team.

Please note:

• if the nominated GP is part of a partnership that uses one practice number, then the member can nominate this partnership practice and visit any GP in that partnership. A partnership practice is a GP practice consisting of a number of different General Practitioners,
• group practices consists of a number of different disciplines i.e. physiotherapists, dieticians, GPs and Specialists and usually fall under the practice type 50. If the beneficiary wants to nominate the GP in the group practice then the individual GP's practice number must be captured and not the group practice number, and 
• if a locum (stand-in) doctor is representing the nominated FP/GP, that locum doctor will automatically be considered as the nominated GP.

7. Can a member change the nominated GP?

Yes, the nominated network GP may be changed once every six months from the date of the last change.

A list of network GPs can be found on the GEMS website at www.gems.gov.za, members may also contact GEMS on [email protected] or 0860 00 4367 or GEMS, Private Bag X782, Cape Town, 8000 or at the nearest GEMS Walk-in Centre.
 
8. Why must a member nominate a General Practitioner on the GEMS network?

The GP's on the GEMS network are contracted to GEMS to deliver cost effective and quality healthcare to GEMS members.  All GEMS contracted GPs are monitored and measured on cost effectiveness and quality of service delivery. 

No co-payments will be due when you see a GEMS network GP (subject to benefits).

9. What happens if the member visits a non-nominated GP, Non-Network Dentist or Optometrist?

If a member or dependant on the Emerald Value Option chooses to visit a GP that is not their nominated GP, a 30% co-payment will apply to all out-of-hospital visits to a non-nominated GP - irrespective of the GP being on the GEMS network or not.

Also, a 30% co-payment will apply to all out-of-hospital visits to a non-network Dentist or Optometrist.  

10. Can a member have more than one nominated GP?

Yes, a GEMS member can have up to two nominated GPs.  The list below contains examples of when a GEMS member may need a second nominated GP. Note: the list below is not exhaustive:

• when parents are divorced or separated and children live in different locations with each parent at different times,
• where a person's work is of such nature that he / she is situated at different locations for a period longer than three (3) months at a time. For example, a member who lives in a township and works in the city and wants a GP in both places,
• when children are at boarding school,
• when children are in foster care, living with grandparents or extended family member(s).
• when members have to travel for work or are involved in special projects for work.
• when students are studying away from home.
• members with a chronic condition who visit a different GP for their chronic condition. For example, a member with diabetes may visit a GP who has a special interest in diabetes, who may not necessarily be their nominated GP.

11. How are members informed about GP nomination?

Members will be informed when they phone the GEMS call centre to nominate a GP. Communication will be sent to members confirming which GP they have been nominated.

The Scheme will send letters, SMSs and remittance statement messages to members reminding them to consult with their nominated GP. Members are encouraged to present their SMS/letter to the doctor at the time of their consultation.

12. How are GPs informed about their nomination?

GPs are informed about their nomination through:

• monthly emails indicating which members have selected them as their nominated FP/GP, and
• SMS or letter confirmation presented by members

13. Does a GP Nomination/Non-Network Dentist or Optometrist Rules apply to in-hospital and out-of-hospital consultations?

No, GP nomination/Non-Network Dentist or Optometrist rules only apply to out-of-hospital consultations. If an EVO patient:

• visits a non-nominated FP/GP/Non-Network Dentist or Optometrist out-of-hospital, the consultation will carry a co-payment, and
• is treated by a non-nominated FP/GP/Non-Network Dentist or Optometrist in-hospital, the consultation will not carry a co-payment.

14. What happens if a member wants a second opinion from another GP i.e. a GP that is not nominated?

For members on Emerald Value, a 30% co-payment will apply to all out of hospital visits to a non-nominated GP - irrespective of the GP being on the GEMS network or not. This includes visits to non-network Dentists or Optometrists

15. What happens if a member has an emergency consultation?

For members on Emerald Value, a 30% co-payment will apply to all out of hospital visits to a non-nominated GP - irrespective of the GP being on the GEMS network or not. Access to this benefit is not automatic. You need to contact us by calling the call centre on 0860 00 4367 or sending an email to [email protected] to ensure that you do not incur a 30% co-payment for such a visit.

Emergency visits will be dealt with retrospectively via the current emergency exception management process similar to PMBs.  An override will be applied to these emergency cases. 

16. What happens if a member sees a GP in casualty (who is not their nominated GP)?

If a member is on Emerald Value option, a 30% co-payment will apply to all out of hospital visits to a non-nominated GP - irrespective of the GP being on the GEMS network or not.

17. How does GP nomination affect procedures that are performed in the GP's room i.e. in-room procedures?

A 30% co-payment will apply to all out of hospital visits to a non-nominated GP - irrespective of the GP being on the GEMS network or not.

Certain in-room procedures are covered at 200% and these are subject to pre-authorisation. These procedures will only be approved if requested by the nominated GP.

18. What happens if there is no GEMS network GP in close proximity to the member?

Cases where a network GP is not within close proximity to a member will be dealt with on an exception management basis. 

Once all efforts by the contracting team have failed to contract the non- network GP, an override will be performed on the member's profile i.e. the doctor will be treated as a network GP and be paid as such. 

This will be the case should there be any other circumstances where it is not reasonable for the member to consult a nominated network GP.

19. Must the provider dispensing medication in-rooms be the nominated GP?

Where medication is dispensed in the rooms by a non-nominated GP, no co-payments will be applied to the medication.

However, a 30% co-payment will apply to all out-of-hospital visits to a non-nominated GP - irrespective of the GP being on the GEMS network or not.

20. Is it a requirement that the referral provider of pharmacy claims (prescribed acute) be in line with the nominated GP?

No, it is not a requirement.

However, where acute medication is prescribed by a non-nominated General Practitioner and dispensed by a pharmacy, no additional co-payments will be applied other than the 30% co-payment that applies to acute medication that is out-of-formulary.

21. Is a GP nomination only for GP's or must there be a selection of providers for other disciplines as well?

Members and their dependants joining the Emerald Value Option must nominate a GP who will be their primary care coordinator. No other disciplines may be nominated as a GP. Members and dependants are allowed to nominate a secondary GP if is required.

Members and their dependants are not required to nominate any other provider disciplines.

Members that join the Emerald Value Option must utilize any one of the Scheme's network hospitals in the case that hospitalization is required. If they elect to not use one of the Scheme's network hospitals, a co-payment of up to R10 000 may be payable.

22. Will the GPs have special tariff rates?

No. The nominated GP will be a network GP and will be reimbursed as per the network GP rules.

23. During hospital admission, will any GP even out of network be allowed to treat the patient? Is there a need for specialist referrals?

It is required that the nominated GP admits a patient into a hospital. Once in hospital, the GP and Specialist referral rules will not apply.

24. Hospital admission, can a Specialist admit an EVO patient to hospital?

Yes, a Specialist can admit an EVO patient into hospital irrespective of whether there was a referral from the nominated GP to the Specialist. Hospital network rules will be applied.

25. Will emergency consultation with non-network GPs be covered? If yes, what is the procedure to follow?

A 30% co-payment will apply to all out of hospital visits to a non-nominated GP - irrespective of the GP being on the GEMS network or not.

Emergency visits will be dealt with retrospectively via the current emergency exception management process similar to PMBs.  An override will be applied to these emergency cases.