Namibian Association of Medical Aid Funds Trustee Training 20th July 2018 Prepared by: Stephen Tjiuoro NAMAF CEO

Table of contents The industry Challenges facing the Industry Health Provision / Market Conduct Management of the Association Namibian Situation Legal Basis To Regulate Market Conduct Conduct Supervision Total Contribution by the 9 Funds Relative Expenditure Stakeholders Coding Structure Practical Example of what Namaf should be supervising November 18

The Health Citizen / MAF Consumer The Industry The Health Citizen / MAF Consumer Savvy who is affected by information asymmetry 29.65 years avg contribute N$3550 pm Pay 22.15% out-of-pocket expenses Exposed to 18% health inflation vs 3.8% CPI Health benefits depletes mid-year 89 692 principal members covering 196 296 lives (2017 financial year) Contributed N$3.8 billion (2017) 8.28% or N$318 million of his contribution was taken up by Administrators, Managed Care Services, NAMFISA and NAMAF Administrators / Managed Care took N$309 million or 8.06% MAF Act mandated NAMFISA to ensure prudential management of these N$3.8 contributions with only N$1.7 million or 0.03% NAMAF to ensure proper functioning of MAF’s and servicing of 196 296 lives through procedure coding and risk management interventions with only N$7.3 million or 0.19% July 18

The challenge Accessibility ± 1.65 million employed Namibians 196 296 lives belong to NAMAF funds – N$4.1 billion (projections 2018) ± 250 000 lives covered by PSEMAS – N$2.5 billion (budget 2018/9) ± 1.2 million Namibians who are employed are uninsured plus the rest of the unemployed – N$6.5 billion of which 65% is non healthcare expenditure leaving only (N$2.3 billion) to cater for 82% of the uninsured population March 18

Health Provision / Market Conduct Registration S22 & S24 Effect of Registration – Juristic Body (S26) Perform functions / exercise duties ito its rules Own assets and liability to the exclusion of anyone MAF’s Juristic Body (Section 10) Control, promote, encourage and coordinate functioning of MAF in Namibia Powers and functions contained in S12 NAMAF November 18

Management of the Association (Sec 13) NAMAF MC Co-opted members and committees Sec 15 Authorized Representatives (sec 13 (2)) Board of Trustee (Sec 13(3)) March 18

“Prudential” Regulation Namibian Situation “Prudential” Regulation “Conduct” Regulation NAMFISA NAMAF November 18

Legal Basis to Regulate Market Conduct Namaf Shall from time to time make rules to direct the conduct of Funds This rules shall take legal effect only when gazetted Management shall have powers to discipline Funds if they contravene these rules November 18

Conduct Supervision Component Application Consumer protection Adherence to contracts (e.g. adherence to fund rules, procedure codes and MCO principles) Distribution of products Are consumers able to make informed purchasing decisions (e.g. in terms of the fund and the benefit option that they are selecting) Maintaining of consumer confidence in industry Fair and consistent treatment of consumers (i.e. similar circumstances are consistently treated in similar ways via, for example, clear billing rules and guidelines) Claims management Risk management Fair and reasonable prices Benchmark tariffs that can be used as yardsticks Beneficial and compliant products Beneficiaries are not unduly compromised as result of their health status and/or age Benefit options offer value for money Benefit options are compliant with national health policy objectives Compliance with laws and regulations Medical and Dental Act Health Facilities Act Immigration Act Medical Aid Funds Act 9 July 18

Total Contributions 9 Funds Affiliated to Namaf Income from Contributions Q4 2017 2017 Q1 2018 295 408 147 1 180 031 533 321 270 074 330 060 774 1 340 984 971 344 058 573 136 938 538 534 002 279 152 928 654 79 736 688 320 946 094 86 881 348 51 440 355 202 620 392 53 489 706 7 014 727 27 560 327 8 069 758 31 757 353 121 818 876 32 168 878 22 739 082 90 514 069 24 644 670 2 150 557 9 804 719 2 411 736   957 246 221 3 828 283 260 1 025 923 397 July 18

Relative expenditure November 18

Clinical Best Practice/Evidence Based Medicine/Ethical rules Member/Patient Practitioner Medical Aid Fund NAMAF Administrator Clinical Best Practice/Evidence Based Medicine/Ethical rules Stakeholders

Coding structures Components Costing Scope of practice Clinical Evidence Time Practice Costs Conversion Factor Reference Price Relative Value Terminology Code X = Responsibility Value Professional Remuneration Billing guidelines and interpretations Billing rules

Pre-authorisation July 18

NAMAF Procedure Codes Comment: The description of code 3134 matches the description of the authorised procedure exactly If the two procedures described by Code 3134 were to be performed independent of each other at separate occasions, it would be appropriate to use either code 3130 or 3199 on their own The practise of coding steps of a procedure as opposed to complete procedures is termed “unbundling” which is undesirable The same procedure on both eyes during the same session was authorised, meaning that it would be appropriate to charge for code 3134 twice, but Modifier 0005 should be applied for the second eye due to after-care happening concurrently Correct account would be to charge for code 3134 plus the administration of local anaesthetics November 18

Actual Account Note: No modifier 0005 applied Incorrect – not authorised Incorrect – included in code 3134 Correct Doubtful – doctor owns theatre X ?  Note: No modifier 0005 applied N$ 17 880 incorrectly billed N$ 595.60 potentially incorrectly billed N$ 9 348.76 correctly billed (ignoring Modifier 0005) November 18

Thank You July 2018