WELCOME to your HERITAGE HEALTH MEDICAL AID FUND Newsletter
We publish Newsletters at regular intervals to keep our members informed, to motivate new readers to join Heritage Health Medical Aid Fund and to be of service to you. In the Newsletters we will be addressing issues such as improving your health, how to manage your benefits and the associated costs, how risk is managed, and your responsibilities. You may also contact us on topics that you wish to be addressed.
Healthcare Costs and Your Responsibility as a Member
Members of medical aid funds play a key role to maintain costs and to prevent medical aid funds from taking high annual increases on the monthly medical aid contributions. It is important to always consider the following TIPS to manage healthcare services.
- Know your Benefits, Rules and the Terms and Conditions of your medical aid cover prior to seeing your healthcare provider. Understand your benefits and the sub benefit limits. Make sure the benefit plans you choose will fit your needs.
- When referred to screening/scanning tests it is important that you always ask the costs prior to going for the tests. It is incorrect to assume that because you have medical aid cover the costs will be covered. Different plans have different levels of cover. The referring doctor is not aware of your available benefits for a specific test.
- When being sent for pathology tests, know what and why tests are taken and ask the costs as these tests are costly and you may have insufficient benefits.
- When receiving a prescription understand the contents.
- Always establish whether a less costly test is available and thereby extend your benefits for the year. It is also important for you to know upfront what your out of pocket payment will be where the tests exceed your available benefits.
- Make smart lifestyle choices. You can reduce your chances of developing a chronic condition or needing to be hospitalized by eating a balanced diet, staying active and avoiding risky behaviours, such as smoking.
- Your medical aid fund will not pay for pre- admissions (one day early admission in a hospital prior to the procedure) as the costs are not justified.
- Your medical aid fund will not allow admissions in a hospital for tests to be undertaken. Admissions are based on a clinical diagnosis and a treatment plan.
- Have the right attitude and do not think that because you have medical aid cover you can randomly use it. All costs have a direct impact on the monthly contributions that you pay. Don’t request medical care when it is not required.
- Always check your invoices and ensure that what is being invoiced is what you received.
- Fraud and abuse is a reality and members have a responsibility to report such incidents.
- You play a key role as a member of your medical aid fund and when uncertain, always ask before incurring the costs.
What is UNDERWRITING
Clients joining a medical aid fund do not understand why waiting periods and exclusions have been imposed on their membership. The primary purpose of underwriting by a medical aid fund is to manage the risk and to take accountability for all the members belonging to that fund. Generally, applies to hospitalisation.
Some of the key aspects being considered when underwriting is being undertaken is: age, (life expectancy) general health (specifically chronic conditions and medication(s)), plan of cover opted, any immediate high-cost clinical condition and whether you are joining as an individual or under an employer group.
When persons who have belonged to a South African medical aid fund now come to Namibia permanently they are often unable to remain on their South African medical aid fund. Heritage Health currently is the only medical aid fund in Namibia who does not apply a cut of age bracket, however the risk must be managed. Sadly, members are unable to include their portion of the reserve build-up from their previous medical aid fund to another medical aid fund and which attributes to the underwriting conditions being applied.
When joining as a new member there is a general three month waiting period or condition-specific waiting period(s) or exclusion(s).
Medical aid funds are compelled to build up reserves and a key to achieving this is managing risk and product design. When persons join and are not being subjected to underwriting conditions and have a high-cost procedure undertaken and terminate cover thereafter the remaining members face the cross-subsidisation of such costs and the impact that it has on the increases to the monthly contributions.
The Board of Trustees have a fiduciary duty to consider the interest of all the members when underwriting is being undertaken on all new membership applications. it will not be fair to all the other members where the risk is not being managed in terms of sound corporate governance principles and the actuarial guidelines.
Exclusions or Limitations of Certain Benefits under medical aid funds:
Limitations on cover are appropriate where they permit a degree of financial risk management. Medical aid funds have exclusions implying that such services will not be paid.
The following principles is considered to determine exclusions and whether it is justified:
- Best practice
- Evidence-based healthcare
- Clinical protocol
- Cost-effectiveness (affordability)
- Laws of the country
Conditions or circumstances that are not excluded are those that are medically necessary. Conditions requiring urgent treatment to prevent death or permanent disability is not excluded. Cosmetic procedures are generally excluded, treatment for obesity, sterilisations, sleep therapy, certain medication items etc. It is important for members to be aware of the exclusions under their cover.
Listeriosis/Food Poisoning caused by Eating Foods Contaminated with the Listeria bacteria and is a bacterial infection
Informative sites regarding Listeriosis and we have used the World Health Organisation. Cooking kills the listeria bacteria. Cooked food must be kept separate from raw food and utensils used on raw food must not touch cooked food‚ to avoid cross-contamination.
Why you MUST Manage Your Weight and Drink Plenty of Water Daily – Your Lifestyle
We often tend to think that when we become older we will apply a healthy lifestyle when in fact the older we become we start reaping the effects of a previous unhealthy lifestyle. Why Is Healthy Weight Important? If you are overweight or obese, you are at higher risk of developing serious health problems, including heart disease, high blood pressure, type 2 diabetes, gallstones, breathing problems, and certain cancers.
Your weight does have an impact on your joints. Did you know that when you are overweight and require a joint replacement (knees, hips) that the fees being charged by the hospital and orthopaedic surgeon are higher and which has a direct impact on the medical aid fund?
Drinking Water helps Maintain the Balance of Body Fluids. Your body is composed of about 60% water. Your body uses water in all its cells, organs, and tissues to help regulate its temperature and maintain other bodily functions. Because your body loses water through breathing, sweating, and digestion, it’s important to rehydrate by drinking fluids and eating foods that contain water. Water can assist you in managing your weight as it is 100% calorie-free, helps you burn more calories.
It is a very easy way to cut back on sugar and calories. One way of measuring your weight to be safe or not is by using the Body Mass Index, BMI. BMI does not consider age, gender, or muscle mass. Nor does it distinguish between lean body mass and fat mass. As a result, some people, such as heavily muscled athletes, may have a high BMI even though they don’t have a high percentage of body fat. By calculating your BMI, you will have an indication of safe weight, lose weight or being under weight.
How do I calculate my BMI?
To work out your BMI:
- divide your weight in kilograms (kg) by your height in metres (m)
- then divide the answer by your height again to get your BMI
- Underweight = <18.5
- Normal weight = 18.5–24.9
- Overweight = 25–29.9
- Obesity = BMI of 30 or more