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Balancing benefits and costs for Medical Aid Funds

Renaissance Health Principal Officer speaks about the prospects for Medical Aid Funds

 

Renaissance Health Principal Officer Sonja Malan says that sustainability of Medical Funds depends on ongoing evolution of Fund offerings to individual and group members.

She sketched out a scenario in which members of Funds are increasingly placed under pressure by general inflation, as well as medical inflation. This, she said, leads to difficulty for Funds when increases in medical costs require them to increase their costs.

She said that Funds accept the moral obligation to care for the health of members with various products however as Funds are mutually owned by members, the burden of members paying for the health requirements of other members, through unused portions of individual member benefits, would lead to an unfavorable assessment of value received for contributions.

However Malan also pointed out that cost-cutting and benefit reductions are not desirable as this would leave members exposed with a limiting suite of services which might not cover the needs of individuals, and might also not provide optimum revenue to medical professionals and related medical services. Cost cutting, she said, could reduce the sustainability of Funds in the long term, and deprive individuals and groups of a valuable safety net.

Members of Funds, Malan counseled, need to understand that although they may contribute less by selecting products based on savings rather than medical needs, they will run the risk of insufficient benefits if they select products based on savings rather than needs.

In light of this, Malan explained, it is vital for Funds to be innovative in providing a suite of products and benefits that optimally matches the needs of various groups of members according to their financial capability. She once again reiterated that Funds do not seek profit but are subject to the NAMFISA requirement of a reserve of 25 per cent and hence need to maintain an allocated amount of savings in order to cover the Fund’s liabilities/claims exposure. Within this framework Funds have the ability to provide the optimum benefits per product by means of risk sharing.

In addition to providing optimum benefits within different product categories, Malan said that Funds have an obligation to seek opportunities for innovation to provide for better member health.

She pointed out Renaissance Health's introduction of complementary benefits to assist members to better manage their health as a case in point. She said the suite of complementary benefits was designed to assist members to manage their health proactively. As members manage their health, the cost of the complementary benefits is offset by advances in health and incrementally lower claims on the Fund.

She highlighted the maternity benefits among the complementary benefits, saying that the ability of female members to be proactive regarding maternal health improved the health of newborns. She also said that the health of members with HIV was also provided for and prolonged with a specific benefit.

Talking about individual and family expenditure, Malan said that over-expenditure of benefits by members is a challenge faced by all Medical Aid Funds in Namibia. She said that Renaissance Health provided ongoing reminders to members to check their benefits and conserve for the event of serious needs.

She also said that when certain benefits were depleted by individual members, Renaissance Health provided members with the ability to 'top up' benefits in specific categories such as GP visits, medications, oral and ocular care with benefit builders, a unique product offering to Renaissance members.

In conclusion she stated the medical industry in both the private and public sphere face various challenges. and in promoting the long term prospect of Medical Aid Funds, co-operation among all stakeholders is a cardinal element, within the greater context of providing access to quality healthcare for the general Namibian population at large.

 

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Renaissance Health Medical Aid Fund
The Renaissance Health Product Guide for 2015 has been released. The product guide will be posted to members, made available in workplaces and will be available in Prosperity Health offices across Namibia. You can also download the brochure on The Renaissance Health Product Guide for 2015 has been released. The product guide will be posted to members, made available in workplaces and will be available in Prosperity Health offices across Namibia. You can also download the brochure on http://www.renaissance.com.na/products/summary-of-benefits Here is a summary of the major changes for 2015. IN-PATIENT BENEFIT CHANGES All beneficiary and family sub-limits have been adjusted with a 6% increase across all Options. NEW: SELECTIVE SURGICAL PROCEDURES * A new benefit category has been introduced for selective surgical procedures that are completed in doctors’/specialists’ rooms or unattached theatres. * This benefit will be part of the overall annual limit and any procedure will be covered at 225% of tariff similar to such a procedure being done in hospital. This is mainly to encourage and reward health professionals for doing minor procedures in practice rather than incurring additional costs for doing it in hospital or a day theatre. NEW - MENTAL HEALTH BENEFIT * A new Mental Health Benefit has been created as part of the overall annual limit; each beneficiary has 21 treatment days available per annum subject to clinical protocols. THE HIV/AIDS BENEFIT * Health Is Vital has been adjusted with a 6% increase across all Options. * HIV/AIDS medication remains to be paid at 90% of NRP with a maximum of N$50.00 levy per script. * Few members have exceeded their available benefits for the current year and we appeal to members to be compliant with their medication and tests to ensure the best quality of life and to prevent any relapses. DAY-TO-DAY BENEFIT CHANGES * All beneficiary and family sub-limits have been increased with 6% across all Options. PROFESSIONAL SERVICES: * Consultations have been increased with 2 additional consultations; * The Psychiatric Treatment Benefit has been moved from the Essential Services Benefit to the Professional Service Limit to provide for a separate and improved benefit limit. NEW - MEDICAL REPORTS * To ensure the best medical and clinical outcomes for patients/members the Fund practices internationally accepted managed care programs and protocols. This requires that doctors have to submit certain medical reports to the Fund’s medical advisors, normally 6-monthly. A new benefit has been created to reward your GP and Specialist for this and an administration fee for chronic patient motivations (this is not applicable to ordinary prescriptions for chronic medication) has been introduced: * Maximum of two motivations per beneficiary per annum to be paid at tariff; * The benefit requires a treatment plan and the registration as a chronic patient. HEARING AIDS AND WHEELCHAIRS - EXTERNAL APPLIANCES * The sub limits have been removed and hearing aids and wheelchairs will be paid at 90% of the benefit subject to a 2 year waiting period and the benefit available per Option. * Optical Benefit: The limitations on the eye tests have been removed and this will now be an inclusive benefit within your Optical Benefit. * Dentistry Benefits have been increased with 12% across all Options to align the Renaissance benefits with the market benchmark benefits. * Pharmacy Initiated Therapy and OTC medication have been increased with 6% in benefits and the maximum script benefit. CHANGES TO VITAL AND PRIMARY CARE * All Vital and Primary Care members are informed that as of 01 January 2015 a maximum income limit will be applied to these two Options on income bands. * On Vital Care: the maximum income limit will be N$ 9 000 and * On Primary Care: the maximum income limit will be N$ 12 000. * Members affected by these changes should select another suitable Option on the Fund. NEW - FAMILY BENEFIT BUILDERS * The Benefit Builders have been restructured to include an “all inclusive day-to-day” benefit block. * This will enable families to finance additional cover and to use the Benefit Builders for all day-to-day benefits such as professional services, medicine, dental and optical. * The 2015 Family Benefit Builders offer 10 levels on which the member can finance additional cover at a 90% of the contribution of the Benefit Builder purchased, pro-rated from date of cover. NEW - FAMILY BENEFIT WALLET * The introduction of a new benefit plan referred to as the “Benefit Wallet” , i.e. a “Top-Up” benefit layer has been introduced for 2015. All members that have acquired a Benefit Builder will transfer 80% of their unclaimed 2015 Benefit Builder benefits to 2016 and thereafter. * This benefit has been established to create a wallet of benefits that can be used in future for medical expenses. Here is a summary of the major changes for 2015. IN-PATIENT BENEFIT CHANGES All beneficiary and family sub-limits have been adjusted with a 6% increase across all Options. NEW: SELECTIVE SURGICAL PROCEDURES * A new benefit category has been introduced for selective surgical procedures that are completed in doctors’/specialists’ rooms or unattached theatres. * This benefit will be part of the overall annual limit and any procedure will be covered at 225% of tariff similar to such a procedure being done in hospital. This is mainly to encourage and reward health professionals for doing minor procedures in practice rather than incurring additional costs for doing it in hospital or a day theatre. NEW - MENTAL HEALTH BENEFIT * A new Mental Health Benefit has been created as part of the overall annual limit; each beneficiary has 21 treatment days available per annum subject to clinical protocols. THE HIV/AIDS BENEFIT * Health Is Vital has been adjusted with a 6% increase across all Options. * HIV/AIDS medication remains to be paid at 90% of NRP with a maximum of N$50.00 levy per script. * Few members have exceeded their available benefits for the current year and we appeal to members to be compliant with their medication and tests to ensure the best quality of life and to prevent any relapses. DAY-TO-DAY BENEFIT CHANGES * All beneficiary and family sub-limits have been increased with 6% across all Options. PROFESSIONAL SERVICES: * Consultations have been increased with 2 additional consultations; * The Psychiatric Treatment Benefit has been moved from the Essential Services Benefit to the Professional Service Limit to provide for a separate and improved benefit limit. NEW - MEDICAL REPORTS * To ensure the best medical and clinical outcomes for patients/members the Fund practices internationally accepted managed care programs and protocols. This requires that doctors have to submit certain medical reports to the Fund’s medical advisors, normally 6-monthly. A new benefit has been created to reward your GP and Specialist for this and an administration fee for chronic patient motivations (this is not applicable to ordinary prescriptions for chronic medication) has been introduced: * Maximum of two motivations per beneficiary per annum to be paid at tariff; * The benefit requires a treatment plan and the registration as a chronic patient. HEARING AIDS AND WHEELCHAIRS - EXTERNAL APPLIANCES * The sub limits have been removed and hearing aids and wheelchairs will be paid at 90% of the benefit subject to a 2 year waiting period and the benefit available per Option. * Optical Benefit: The limitations on the eye tests have been removed and this will now be an inclusive benefit within your Optical Benefit. * Dentistry Benefits have been increased with 12% across all Options to align the Renaissance benefits with the market benchmark benefits. * Pharmacy Initiated Therapy and OTC medication have been increased with 6% in benefits and the maximum script benefit. CHANGES TO VITAL AND PRIMARY CARE * All Vital and Primary Care members are informed that as of 01 January 2015 a maximum income limit will be applied to these two Options on income bands. * On Vital Care: the maximum income limit will be N$ 9 000 and * On Primary Care: the maximum income limit will be N$ 12 000. * Members affected by these changes should select another suitable Option on the Fund. NEW - FAMILY BENEFIT BUILDERS * The Benefit Builders have been restructured to include an “all inclusive day-to-day” benefit block. * This will enable families to finance additional cover and to use the Benefit Builders for all day-to-day benefits such as professional services, medicine, dental and optical. * The 2015 Family Benefit Builders offer 10 levels on which the member can finance additional cover at a 90% of the contribution of the Benefit Builder purchased, pro-rated from date of cover. NEW - FAMILY BENEFIT WALLET * The introduction of a new benefit plan referred to as the “Benefit Wallet” , i.e. a “Top-Up” benefit layer has been introduced for 2015. All members that have acquired a Benefit Builder will transfer 80% of their unclaimed 2015 Benefit Builder benefits to 2016 and thereafter. * This benefit has been established to create a wallet of benefits that can be used in future for medical expenses.
Summary of Benefits
Summary of Benefits
www.renaissance.com.na
Namibia Medical Care Website
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