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

2. 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

3. 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
principal members covering 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 lives through procedure coding and risk management interventions with only N$7.3 million or 0.19%
July 18

4. The challenge Accessibility ± 1.65 million employed Namibians
lives belong to NAMAF funds – N$4.1 billion (projections 2018)
± 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

5. 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

6. 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

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

8. 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

9. 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

10. Total Contributions 9 Funds Affiliated to Namaf
Income from Contributions
Q4 2017
2017
Q1 2018
July 18

11. Relative expenditure
November 18

12. 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

13. 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

14. Pre-authorisation
July 18

15. 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

16. 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$ incorrectly billed
N$ potentially incorrectly billed
N$ correctly billed (ignoring Modifier 0005)
November 18

17. Thank You
July 2018