THE EFFECTS OF MEMBERS’ CLAIMS ON THE IMMEDIATE FUTURE OF THE
BENEFIT STRUCTURE OF MEDICAL AID FUNDS
edical aid funds are need to be settled out of the fund’s reserves.
• visit healthcare providers;
based on the principle Measures to increase reserve levels reduced by Contracting with managed care organisations
of solidarity; members to ensure the costs of healthcare are appropri-
Mpooltheirfunds to pay for medical high claims ately contained.
expenditure that an individual could If the reserve level of the fund reduces significantly What members can do to reduce the claims level
not have budgeted for efficiently. The over a short period of time the fund may be forced to
principle of solidarity and pooling do one or more of the following: Medical aid fund members own the fund and have
funds both help reduce the burden of
• Implement high increases in monthly member a responsibility to ensure that they control the
healthcare expenses on individuals who contributions, with assistance from actuarial claims cost of the fund. The fund is established,
would not be able to budget reliably for consultants; and members join the fund, with the intention
their healthcare expenditure.
• Redesign benefit packages to reduce benefits of paying the healthcare costs of members. The
Members of the medical aid fund contribute to offered by the fund in order to implement sustainability of the fund relies on the responsible
minimum contribution increases; or Require the behaviour of the fund members.
the pool of funds, and from this pool healthcare
members to make high co-payments to access
costs, or claims, are paid. Medical aid funds in There are a number of ways in which members can
medical services; or
Namibia are required to hold 25% of their annual
• In extreme cases the fund members may have to pro-actively reduce their claims costs, including:
contributions in reserves. This is called the fund’s
reserve level. In order to maintain a healthy reserve collectively decide that the fund be terminated.
• Participating in health and wellness programmes
level the fund has to increase its contributions in to reduce the risk of falling victim to chronic
How the medical aid fund board reduces the diseases;
proportion to medical service prices and increases,
•and manage its claims costs. negative impact of high claims Requesting prescriptions for generic medicines
Claims costs can reduce the reserve levels of the fund if from health practitioners to reduce early
The fund’s management, or board of trustees,
• depletion of medicine benefits;
they continually exceed contribution income. Reducing Consulting general practitioners (“GP”), and
implements measures to reduce the negative
reserve levels can threaten the continued sustainability impact of excessive claims, some of which include: only consulting specialists on recommendations
and existence of the medical aid fund. For example, if from the GP.
• Investing extra cash to supplement operating
fund A collects contributions of N$2,000 in year 1 and
incurs claims costs of N$2,050 during the same year, surpluses – the money remaining after health- Members’ claims behaviour directly impacts the
care and non-healthcare costs are deducted
N$50 will have to be funded by the reserves. Beyond the
future operation of the fund. Therefore, medical aid
claims expenditure, other non-healthcare costs including
• from contribution income; fund members and their dependents are cautioned to
administration costs, managed care organisation fees, Educating members on responsible be- consider the impact of their claims on the future of the
consultancy fees and operational expenses would also haviour, which would reduce their need to fund when utilising the fund’s healthcare benefits.