To ensure the best possible protection of Government employees in general but specifically frontline health care workers across the country, the Government Employees Medical Scheme (GEMS) wishes to encourage its members who show flu-like symptoms to get tested for COVID-19.
The National Department of Health projected that more than 60% of South Africans will get the COVID-19 disease and 20% will be severely affected. Consequently, this has led to increased levels of anxiety and panic across the country. GEMS seeks to appeal to its members not to panic but to be informed about how the COVID-19 will impact us as members of GEMS. Actuarial estimates are that the Scheme will spend around R900 million towards treatment and care for members who contract COVID-19. The R900 million spend largely come from the risk benefits and will not affect the members’ day to day benefits or savings.
“While testing is central to fighting the pandemic, the Scheme is obligated to funding all clinically appropriate care and related costs, including COVID -19 related testing, in line with Circular 25 of the Council for Medical Schemes (CMS) and the Medical Schemes Act of 1998 read with the Scheme Rules”, said Dr Stan Moloabi, GEMS Principal Officer.
GEMS is working fervently to ensure that concerns surrounding payment of all qualifying COVID -19 pathology laboratory claims are addressed and funded as per the June 2020 communication sent to all members. Clinically appropriate testing for COVID-19 is PMB level of care upon referral from a qualified health care worker who would have screened a patient appropriately.
Testing done in line with the National Institute for Communicable Diseases (NICD) and the National Department of Health (NDOH) guidelines will be covered as PMB regardless of the outcome of the test. All PMB benefits are paid first from the appropriate available benefits and then once depleted such claims are paid from risk.
“GEMS members will be serviced and should not be requested to pay for COVID-19 testing upfront. The testing of members where guidelines are not met is not considered as PMB level of care as it is regarded as not clinically appropriate. Therefore, in such instances, once the member’s available benefits are depleted, the member may face co-payment”, concluded Dr Moloabi.
The Scheme is committed to supporting efforts made by members to curtail the spread of the virus with the aim of flattening the curve of infections and reduce the toll on human lives.
Members should take solace in knowing that testing for COVID-19 will be covered, provided it is clinically appropriate. Ideally, beneficiaries should ensure they are screened first by a nurse/doctor who will then determine if a test is required. Once tests are done, both negative and positive tests will be paid as PMB.
If members have any queries, they may contact the GEMS call centre on 0860 00 4367 or send an email to firstname.lastname@example.org.
Members are again reminded that they can also contact the Government 24hr COVID-19 Hotline at 0800 029 99. The COVID-19 WhatsApp line is 0600 123 456.