Mutual Alliance Health Plan. Why you as an employer should join now

Transcription

1 C519/7 Comcan Crescent, Kpehe, Accra Telephone: (+233) Facsimile: (+233) Mutual Alliance Health Plan Why you as an employer should join now

2 About Mutual Alliance Health Plan The promulgation of the National Health Insurance Act 2003, Act 650 has led to a change in the way that employers must provide for their employees and dependents welfare. According to this Act any resident of Ghana must belong to either the District Mutual Scheme, the Private Mutual Scheme or the Commercial Insurance Scheme. The Commercial Insurance Scheme must lodge a non-interest bearing security equivalent to US$500,000 to operate. As a result none are operating presently. The District Mutual Scheme on the other hand is offering coverage which is less than what a number of employers have hitherto been offering resulting in employees wasting time to be attended at District Mutual Scheme accredited health services providers. This leaves the Private Mutual Scheme as a possible vehicle for employers to provide their employees and dependents with access to quality and cost effective health care. Legally, employers can no longer continue with their arrangements where they pay directly for their employees and dependents health care needs. To comply with the law, they have to do so through any one of the three insurance schemes.

3 Scheme Administration Momentum Ghana has been identified to carry out scheme administration for MUTUAL ALLIANCE HEALTH PLAN. Momentum Ghana will be able to offer the following services to Mutual Alliance Health: Mutual Alliance Health Plan All Risks Consultancy a Ghanaian wholly owned company has identified the aforementioned predicament for employers and is setting up a Private Mutual Insurance Scheme to be known as the MUTUAL ALLIANCE HEALTH PLAN to which select employer groups are invited. The MUTUAL ALLIANCE HEALTH PLAN will be registered as a company limited by guarantee and will be owned jointly by the member employers. The governing body will be a Board of Trustees drawn from member companies. Founding members will have the privilege to appoint representatives onto the Board of Trustees and influence the leadership and direction of the Scheme. Scheme Funds will be lodged with Banks who are Founding Members. JOINING FEE Each company will contribute 5million as Membership Fee to cover start-up costs such as Company registration, NHIS Licence Fees, Scheme Constitution and Rules Handbook etc. A further contribution as per schedule below to Claims Reserve Fund. > Employees up to 50 5million > Employees between 51/250 10million > Employees of 250 and above 15million CLAIMS MANAGEMENT > Processing claims as per benefits applicable to the different plans. Use is made of specialised software and computer equipment. > Identification of claims where claims could be paid by other third parties, for example vehicle accident claims > Prompt payment of clean claims to health services providers and members > Use of data mining methods to detect and prevent fraudulent claims > Claims settlement statements to members > Statement of claims settled to health services providers > Reconciliation of claims paid and claims submitted by health services providers MEMBERSHIP MAINTENANCE > Issuing of membership cards for each beneficiary (with photos) > Billing and receipting premiums > Maintaining an up to date membership register > Provider Network Services > Development of a list of preferred health services providers > Training health services providers bookkeepers on how to expedite the claims submission process > Visiting health services providers to verify that their services are offered in an environment commensurate with fees charged > Provide health services providers with feedback on their performance compared to their peers Employers should provide their employees and dependents with access to quality and cost effective health care.

4 Scheme Administration cont. FIRSTRAND CASHLESS HOSPITALISATION > Ensuring that genuine members are admitted to hospital without the need for cash deposits. Membership cards will be used at the hospital to confirm membership and benefit levels. > Offering a verification system to health services providers so that only valid members receive treatment. Discovery Health (60%) FNB Bank (100%) Momentum Pty Ltd (100%) OutSurance (100%) Cellpay (100%) > Case management to ensure discharge planning as well as clarification of benefits to members while in hospital Momentum Africa HOSPITAL HELP DESK Momentum Botswana > The above will be operated at all Momentum Ghana major hospitals to facilitate members admission into hospital; Momentum Kenya Momentum Lesotho > Onsite verification of membership will be offered > Direct assistance offered to members by Momentum Ghana staff. Momentum Mauritius Momentum Mozambique Momentum Tanzania Momentum Zambia EMPLOYER REPORTS > Quarterly reports to employers on disease prevalence and claims costs SMS ENAMBLED SERVICE > Use of SMS to verify membership by health services providers. Credentials of Momentum Africa Momentum Africa is part of the FirstRand group, one of the top ten companies on the Johannesburg Stock Exchange with a market capitalisation in excess of US$15bln. Momentum Pty Ltd; the parent company of Momentum Africa is the third largest insurance company in South Africa. Momentum Africa s core business is health insurance in Africa. The following figure shows the structure of FirstRand and the position of Momentum Africa within it. Momentum Africa presently has a presence in eight countries and Ghana will be the ninth. Across these countries, close to 700,000 lives are covered.

5 Products MUTUAL ALLIANCE SCHEME will offer products that provide for the medical needs of all levels of management from top management (EXECUTIVE PLAN) to the LIFE PLAN for the lower level employees as shown is the table below. Medical cover is split into three sections, that is, Major Benefits, Day-to-day Benefits and Special Benefits. Each section has a limit dependent on the level of cover. Major benefits provide for in-hospital cover. The day-to-day benefits provide for services such as outpatient consultations, outpatients investigations as well as outpatient drugs. Sub-limits will apply for benefits that are likely to be to abused or unduly over utilised so as to contain claims costs. TRADITIONAL PLANS EXECUTIVE CLASSIC LIFE Benefits Categories and Limits Cedis Cedis Cedis Major Benefits Limit 50,000,000 36,000,000 18,000,000 Day-to-Day Benefits Limit 9,000,000 7,000,000 3,000,000 Special Benefits Limit 7,000,000 4,500,000 2,000,000 Premiums Adult 4,500,000 2,000,000 1,500,000 Child 4,000,000 1,800,000 1,300, years and above 9,000,000 4,000,000 3,000,000 TOP-UP PLANS With HIV/ Without HIV/ AIDS Cover AIDS Cover Benefits Limit 50,000,000 40,000,000 Premiums Adult 800, ,000 Child 700, , years and above 1,600,000 1,500,000 MEDICAL SAVING PLANS CEDI medical SAVINGS Bronze Silver Gold Major Benefits Limit 40,000,000 40,000,000 40,000,000 Savings For Day to Day 900,000 1,200,000 1,800,000 Special Benefits Limit 4,500,000 4,500,000 4,500,000 Premiums Adult/Child 1,800,000 2,100,000 2,700,000 BENEFITS There are three classes of benefits with a maximum for each. The major benefits limit which is subject to preauthorisation can only be exceeded if the employer makes a written undertaking to pay the excess within 30 days of being billed. In this case the administrator will pay the health services provider and bill the employer. For the day-day-day claims payments to health services providers will be made and if the limit has been exceeded, the excess will be billed to the employer for deduction from the employees salary or for treatment as ex-gratia by the employer. However, an employer can opt to limit their liability to the benefit limits as prescribed. PREMIUM PAYMENTS These will be billed quarterly and are payable quarterly in advance. Where premiums have not been paid, benefits will be withheld and no authorisation of treatment to health services providers will be made. The administrator reserves the right to advise employees of the status of the employer s account should the account be in arrears. Employers that do not pay premiums within 30 days of billing will be terminated and a penalty payment will be required to re-join. BUSINESS MODEL By pooling resources employer groups will be able to take advantage of economies of scale through improved bargaining power. Reserves can be used to develop private health services infrastructure for the benefit of members and the general Ghanaian population. Aggregated information on health services usage and requirements can be used to design products that offer value to members as well as assist in intervention and prevention to reduce down stream costs. WAITING PERIODS Employers will be required to join all their employees onto any one of the MUTUAL ALLIANCE HEALTH PLANS and there will be no waiting periods. However for those employees upgrading from one lower plan to another, a six months waiting period will apply. During the waiting period higher premiums will be paid while member receives benefits of the lower plan. This is meant to discourage the upgrading of employees to higher plans in anticipation of the need for higher utilisation. PREMIUMS Through the use of actuarial information from other African countries premiums and benefits have been set. As more information is collected, the premiums and benefits will be reviewed and approved by the Board of Trustees taking into account affordability by employers as well as the need to ensure that employees have decent cover.

6 Neil Harvey Associates (NHA) Momentum Africa specialises in health care administration and seeks to keep on the cutting edge of technology by concentrating on this core business. In this regard, it has partnered with Neil Harvey Associates, which is a software company that specialises in software development and maintenance for medical aid and health insurance administration. NHA have been in business for close to 30 years and has a staff complement of 105. Eighty percent are technical staff and the rest administration staff. NHA offers the following products; MEDWARE, CAREWARE AND UPS. NHA also services other health insurers in the Southern African market. Momentum Africa specialises in health care administration and seeks to keep on the cutting edge of technology by concentrating on this core business.

7 Mutual Alliance Health Plan Why you as an employer should join now C519/7 Comcan Crescent, Kpehe, Accra Telephone: (+233) Facsimile: (+233)

8 Mutual Alliance Health Plan Why you as an employer should join now C519/7 Comcan Crescent, Kpehe, Accra Telephone: (+233) Facsimile: (+233)