GetMed provides administration and risk management solutions for small to medium
sized health and wellness business
units such as sick funds, health insurance companies, employer groups or social affinity
groups that offer health and
wellness benefits to their members mainly from the low to middle income communities.
The products managed by GetMed are designed to meet the needs of the many people
from the low and middle income
groups that cannot afford the high cost of subscribing to standard medical scheme
offerings, but aspire to provide
themselves with essential protection against the financial burden of medical care.
GetMed is contracted to manage the following plans:
- GetMed Flexible Health Savings Account;
- GetMed Health Protection Plan;
- Siyaphila Health Protection Plan;
- Getwell Chronic Health Protection Plan;
- Oraclemed International Students Health Protection Plan;
- Sinawe Health Plan
GetMed is also contracted to provide specific administration services in respect
of the following plans:
- Ambledown Workers Crisis Plan;
- Health and Accident Hospital Plans;
- Kelly Group Death and Disability Plans
The GetMed office, located in Centurion, Gauteng, opened for business under its new
management team on 1 June
GetMed's goal is to provide high quality health and wellness benefits administration
and risk management at an
affordable cost to business units focusing their products on the low and middle income
The GetMed managed care plans are targeted at clients with at least 300 members.
Such clients can be employer
groups, employee groups, broker groups or loyalty groups. As the commercial offering
of health and wellness benefits to the low to middle income market segments in South
Africa ranges from non-existent to inadequate, GetMed will grow
with its clients as the market grows and matures. Clients are able to select from
various levels of service, which will be tailored to their needs:
Basic administration of flexible health savings accounts;
- Basic benefits administration and management for health and wellness plans;
- An extended benefits administration and management for health and wellness plans.
GetMed uses uncomplicated administration service level agreements as well as franchise
agreements depending on the
client specific requirements to record the various arrangements with its clients.
GetMed markets its services through
business associates, insurance brokers, local businesses, and professional associations.
GetMed has been established as a private company when the GetMed business was bought
from Igolide during 2004 in
terms on a management buyout. It is GetMed’s vision to become the health and wellness
risk manager of choice for
those business units that carry out their activities based on people employed from
the low to middle economic class.
What does managed care mean in the GetMed context?
It is GetMed’s mission to provide integrated managed care solutions that will address
the needs of the beneficiary, the
health care provider as well as the plan assuring access to affordable health care
of the best quality on a sustainable
basis. In essence, our approach to managed care refers both to programs that coordinate,
rationalise, and channel the
delivery of care for defined health events. Managed care differs from conventional
health insurance in that GetMed
enters into arrangements with providers to provide defined health services in terms
of managed care protocols. In
contrast, a conventional insurer underwrites the coverage without becoming involved
in the delivery system.
GetMed managed care is hands-on health insurance, it combines the responsibility
for paying for a defined set of health
services with an active program to control the costs associated with providing those
services, while at the same time
attempting to control the quality of and access to those services.
The goals of GetMed managed care are to ensure that -
- Health care providers deliver high-quality care in an environment that manages or
- The care delivered is medically indicated and appropriate for the patient’s condition.
- The care is rendered by the most appropriate health care provider.
- The care is rendered in the most appropriate, least-restrictive setting.
To be considered medically indicated, the health service you receive must be:
1. Essential to prevent, diagnose and/or treat a specific condition.
2. Specifically related to the condition being treated or evaluated.
3. Provided in the most medically appropriate setting; for example in an out-patient
setting rather than in a hospital or in-patient facility, unless the services cannot
be provided safely in an out-patient setting.
GetMed implements a managed care model that is funded by one of the following mechanisms:
1. Flexible Health Savings Account regulated by the Financial Services Board;
2. Sick benefit fund registered in terms of the Labour relations Act, 1956;
3. Short term health insurance registered in terms of the Short Term Insurance
- Both mechanisms mentioned in par 2 and 3 are currently underwritten by Constantia
Insurance Company Limited.
Why do we authorise access to health services?
GetMed applies a policy to authorise every access to health services. The reasons
for this policy are to enhance our
relationship with the provider and the member in the following ways:
- GetMed confirms the eligibility of the patient for health services;
- GetMed confirms that the treatment that is requested or proposed is appropriate;
- GetMed protects the managed health care benefit to which the member is entitled;
- GetMed guarantees that the authorised services will be paid according to the confirmed
- GetMed assists the provider to ensure that the patient contribution in respect of
non-covered services or co-payments are recovered timeously;
- GetMed supports the provider to follow required referral procedures or to complete
prescribed documentation in specific cases;
- GetMed is committed to reduce abuse and fraudulent use of benefits to ensure that
the funding plans remain sustainable.
In an effort to keep down the costs of the plan, GetMed negotiates tariffs at levels
that are lower or equal to that what other health plans pay for similar services.
For the higher options of certain plans GetMed agrees to refund health
services at the NHRPL tariffs. As a quid pro quo GetMed undertakes to pay the provider
within 72 hours from the date
that an electronic claim has been received.
GetMed also negotiates the use of treatment guidelines and medicine formularies that
are scientifically and economically justifiable ensuring affordable outcomes based