THE EFFECTS OF MEMBERS’ CLAIMS ON THE IMMEDIATE FUTURE OF THE BENEFIT STRUCTURE OF MEDICAL AID FUNDS
Knowing Your Rights and Responsibilities as a ConsumerMedical 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- Mpool their funds to pay for medical high claims ately contained. expenditure that an individual could If the reserve level of the fund reduces significantly 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:
• Implement high increases in monthly member contributions, with assistance from actuarial consultants;
• Redesign benefit packages to reduce benefits offered by the fund in order to implement minimum contribution increases; or Require the members to make high co-payments to access medical services; or
• In extreme cases the fund members may have to pro-actively reduce their claims costs, including: collectively decide that the fund be terminated.
• 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- Mpool their funds to pay for medical high claims ately contained. expenditure that an individual could If the reserve level of the fund reduces significantly 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:
• Implement high increases in monthly member contributions, with assistance from actuarial consultants;
• Redesign benefit packages to reduce benefits offered by the fund in order to implement minimum contribution increases; or Require the members to make high co-payments to access medical services; or
• In extreme cases the fund members may have to pro-actively reduce their claims costs, including: collectively decide that the fund be terminated.
How the medical aid fund board reduces the negative impact of high claims
Knowing Your Rights and Responsibilities as a ConsumerThe fund’s management, or board of trustees,
implements measures to reduce the negative
impact of excessive claims, some of which include:
• Investing extra cash to supplement operating surpluses – the money remaining after health- care and non-healthcare costs are deducted from contribution income;
• Educating members on responsible be- haviour, which would reduce their need to
• Investing extra cash to supplement operating surpluses – the money remaining after health- care and non-healthcare costs are deducted from contribution income;
• Educating members on responsible be- haviour, which would reduce their need to
What members can do to reduce the claims level
Knowing Your Rights and Responsibilities as a ConsumerMedical aid fund members own the fund and have
a responsibility to ensure that they control the
claims cost of the fund. The fund is established,
and members join the fund, with the intention
of paying the healthcare costs of members. The
sustainability of the fund relies on the responsible
behaviour of the fund members.
There are a number of ways in which members can • Participating in health and wellness programmes to reduce the risk of falling victim to chronic diseases;
• Requesting prescriptions for generic medicines from health practitioners to reduce early depletion of medicine benefits;
• Consulting general practitioners (“GP”), and only consulting specialists on recommendations from the GP.
There are a number of ways in which members can • Participating in health and wellness programmes to reduce the risk of falling victim to chronic diseases;
• Requesting prescriptions for generic medicines from health practitioners to reduce early depletion of medicine benefits;
• Consulting general practitioners (“GP”), and only consulting specialists on recommendations from the GP.
Final Note
Knowing Your Rights and Responsibilities as a ConsumerMembers’ claims behaviour directly impacts the
future operation of the fund. Therefore, medical aid
fund members and their dependents are cautioned to
consider the impact of their claims on the future of the
fund when utilising the fund’s healthcare benefits.