nhi-bill-developments NHI Bill developments

The following Healthcare Newsletter was issued by ACA Employee Benefits - 2019

The proposed National Health Insurance (NHI) system to be introduced in South Africa has drawn much attention in the media over the past months, concluding in the recent announcement that the NHI Bill has been approved by cabinet and submitted to parliament where it will be subject to parliamentary scrutiny.

The Bill aims to provide a package of comprehensive health services, purchased by the NHI Fund, within the state’s available resources. All South-African citizens’ (users) will receive health care services free at the point of care from an accredited health care provider within a reasonable time frame.

The intention is that users must first access health care services at a primary health care level as the entry into the health system and must adhere to the referral pathways prescribed for health care service providers.

Phases of implementation

Phase 1

The first phase covers a period of five years from 2017 to 2022 that will be used as preparation for NHI.

Phase 2

Phase two is a period of four years from 2022 to 2026 and will include legislative changes with NHI to be implemented in 2026.

The future role of medical schemes after NHI has been fully implemented

What the NHI Bill states:

• Once National Health Insurance has been fully implemented as determined by the Minister through regulations in the Gazette, medical schemes may only offer complimentary cover to services not covered by the NHI Fund.
• A person must pay for health care services rendered through a voluntary medical insurance scheme or any other private insurance scheme if that person:
  • is not entitled to health care services purchased by the NHI Fund;
  • fails to comply with referral pathways prescribed by a health care service provider;
  • seeks services that are not deemed medically necessary by the Benefits Advisory Committee or
  • seeks treatment that is not included in the Formulary (prescribed package).

It is therefore clear that medical schemes and other insurance products will continue to exist, given the somewhat conflicting statements above. We believe that allowing medical schemes to cover NHI benefits, will relieve pressure on the NHI system and support the principles of cross-subsidised funding.

ACA will continue to engage through various industry bodies to raise concerns regarding aspects of the Bill which we do not agree with.

Next steps

The Bill will now go through the Parliamentary process with extensive opportunity to debate and provide comments. During the implementation periods mentioned above, a total of 11 different related Acts will need to be changed to align with the proposed NHI legislation. There might be legal challenges throughout this process.

Generation Z, Millennials (Gen X), Baby Boomers – who are they and how do they think about healthcare/medical cover

Let us start by understanding the alphabet of generations - the different naming conventions used for different age groups. Please bear the following in mind:

• Generations are categorised loosely by their birth year, not their current age. People grow older but their birth dates stay the same.
• As time moves on, the needs and aspirations typical of a specific age changes, therefore also of such a generation.
• The birth years quoted in different publications might differ and is merely an indication, rather than cast in stone.

According to Kasasa (April 2019), the first time a generation was categorised, based upon a specific period of birth, was when babies born between 1945 and 1964, in the period of post-World War ll American prosperity, were called the Baby Boomers due to the sheer number of new births and specific characteristics typically associated with them. Shaping events of this generation include the post- World War ll optimism, the Vietnam War and the launch of the environmental movement.

The generation that followed the Boomers didn’t have a historical event as an identifier. That is why the generation following the Baby Boomers was merely called Gen X - illustrating the undetermined characteristics they would come to be known by. Gen X babies were born between approximately 1965 and 1979/1980. Shaping events include the end of the cold war, the rise of personal computing, and feeling lost between the two huge generations.

The generations to follow were identified according to the alphabet. The generation following Gen X naturally became Gen Y, born 1980-1994 (give or take a few years on either end). The term “Millennial” also refers to persons born during those years, currently young working adults.

Generation Y’s are subdivided into Generation Y1 and Generation Y2. This generation’s shaping events include the Great Recession, the technological explosion of the internet and social media, and 9/11.

Generation Z refers to babies born from the mid-2000s through today, although the term isn’t yet widely used. This may signal the end of the alphabet naming convention. A number of potential labels have subsequently appeared, including Gen Tech, post-Millennials, iGeneration, and Gen Y-Fi.

Each Generation, representing groups of people within a category 15 to 20 years apart, has specific characteristics loosely associated with the influence of their different socio-economic environments and the effect of the rapidly changing world, according to Kasasa.

How do different generations engage with their healthcare benefits?

In an article by Monica Majors (Vice President of Marketing and Communications for Sutter Health Plus, published in Managed Healthcare Executive (internet magazine), she describes the differences between the 3 largest groupings – Baby Boomers, Generation X and Millennials.

Baby Boomers (currently between 55 and 70 years of age) have a more expendable income and are less technologically efficient. Yet, they do appreciate the convenience. In terms of healthcare, they would prefer a one-stop-shop, with all services in close proximity without the need for multiple trips to obtain X-rays, have blood drawn, etc. Although according to research in the US, 79 % of Boomers go online daily, they prefer mouth to mouth recommendations to select their healthcare providers. The Boomers are more brand faithful and place a high value on reputation and insurers/providers they can trust. They are the most likely age group to use online physician rating services.

Generation Xers (currently between 39 and 54 years of age) are more discerning and will actively research various sources prior to making healthcare decisions. Due to their busy lives, they also place a high premium on convenience and will typically prefer after hours, walk-in clinics to obtain routine health services, such as immunisations, minor injury treatments and wellness screenings. The older section of this generation requires procedures such as preventative mammograms and colonoscopies and require plans that cover these.

Millennials/Generation Yers (currently between 23 and 38 years of age) expect easy access to information. They value clear comparisons of health plans. They are often emotionally driven and use personal relationships to determine brand loyalty. They easily switch providers after negative experiences. They will prefer online tools, such as portals or mobile apps to engage wellness programs and doctors, also through video visits. They are loyal to brands who engage directly with consumers on social media. Because they require less healthcare, the Millennials prefer plans with savings accounts and prefer discounted contributions in return for co-payments/deductibles.

The article concludes with the statement that navigation of employee benefits in general can be overwhelming – highlighting the importance of clear and concise communication in multiple formats to reach the various needs of different generations.

Retirement medical funding - “the perfect storm”

1. We all know that due to consumer health awareness, advances in medical technology and innovation, people become older. The average life expectancy of a 60 year old South African male and female is around 22 to 24 years.
2. We also know that the advances in medical technology, over a longer time frame, push up the cost of medical care.
3. Thirdly, one’s medical expenses in the last 10 years typically constitute 20% of the medical expenses of your whole life.

The three factors mentioned equates to the “perfect storm” or time bomb in terms of the provision for retirement – specifically in terms of the cost to insure yourself against high-cost expenses through your medical aid.

Most persons approaching retirement, start doing some calculation regarding their retirement funding and typically would use their current medical aid option as a guideline to understand the cost implications of healthcare cover during retirement.

Most employees do not realise this potential burden on their post-retirement finances and are completely underfunded in terms of provision. The table below, provided by Karen Wentzel, Head of Annuities at Sanlam Employee Benefits, gives some indication of the amount to be invested monthly at different ages for males and females to provide for a monthly amount of R3 000 and R5 000 respectively, increasing by CPI plus 3%. This is the minimum rate at which medical scheme contributions have increased over the last number of years. R5000 represents a contribution for an individual on a comprehensive type plan and R3000 would purchase an average cover plan.

A couple, aged 60 would require around R2m to fund for an average medical aid premium of R6 000 per month, increasing by 3%, using a typical life annuity investment as a funder. This is the amount most average earning South Africans have in total to retire.

One could argue that when healthcare funding becomes critically scarce, one could fall back on the state to provide for resources, yet in the South African context, the state facilities are underfunded, overburdened and therefore lacking quality and provide care which the average citizen would not want to use if you have any choice.

Another glimmer of hope could be National Health Insurance (NHI). The reality is that NHI is merely a public sector managed scheme with funding resources from all taxpayers. The concerns regarding sufficient resources and quality of care will always be challenged until proven to be sufficient. The tax benefits related to medical scheme membership and medical expenses are expected to also fall away when NHI is fully implemented.

Retirement age	Comprehensive montdly contribution, for expected life years remaining, increasing by CPI +3%	Required capital to provide montdly funding	Average cover montdly contribution, for expected life years remaining, increasing by CPI +3%	Required capital to provide montdly funding
Male 55	R5000	R1 544 170	R3000	R926 502
Male 60	R5000	R1 313 927	R3000	R788 356
Male 55	R5000	R1 099 905	R3000	R659 943
Female 55	R5000	R1 771 671	R3000	R1 063 003
Female 60	R5000	R1 520 531	R3000	R912 319
Female 65	R5000	R1 281 024	R3000	R768 614

Given the magnitude of the above funding requirements, we would strongly suggest that employees contact their financial advisors to start providing for the capital amounts mentioned above. The easy calculation is always to contribute similar amounts to that required after retirement, for as long as you are expected to have such funding available. If you are 60 years old, your expected medical scheme contribution is R3000 per month and your life expectancy is 20 years, then you need to save R3000 for 20 years to build up the funds required.

Reviewing your medical scheme option

It is that time of the year again.

The Medical Schemes Act allows members of medical schemes to annually select an option to suit their needs. That is why ACA Employee Benefits puts in a huge effort during the review period (October and November) to inform members of the changes to their current option and other options of their scheme, in order to assist with such a decision, effective 1 January, if required.

According to Jacques van der Merwe, Regional Manager of ACA Employee Benefits, the following aspects are of importance:

• Establish if your family composition, their health or your financial position has changed substantially. If not and there are also not substantial changes in your current medical scheme option, or other options available, you may consider to remain on the same option.
• If the above-mentioned aspects have changed or are expected to change, we would embark on a process to review the option selected. The process would typically involve matching your family’s healthcare needs with available options, subject to affordability.
  • We would consider the different benefit categories offered, starting with hospital cover, chronic medication cover, day to day cover and finer details within these, to match the needs of clients.
  • It is important to understand how contributions can be lowered by limiting yourself to choices by using a network of providers.
  • Sometimes a completely different benefit structure is required to match changing needs. In this regard, a traditional- or network type plan can be considered as an alternative to a new generation savings type plan or vice versa.
  • Sometimes, it is necessary to consider funding certain expenses out of your own pocket to limit contributions, resulting in net savings.
  • It might be necessary to consider supplementary products, such as GAP cover, to address risks/cover needs.

Medical Schemes only allow for option changes with effect 1 January of each year and it is therefore very important to consider alternative solutions during year-end, under guidance from our consultants.

Industry shorts…

• During the past year, two amalgamations between open schemes were approved – continuing the trend of consolidation in this market. Topmed Medical Scheme merged into Fedhealth Medical Scheme with effect 1 August and Selfmed Medical Scheme merged into Compcare Wellness Medical Scheme. We support mergers between smaller schemes where profiles are compatible and result in a better consolidated financial- or profile position.
• It seems that the proposed Medical Schemes Amendment Bill comments are still being considered, pending the release of the final report of the Health Market Inquiry on 30 September. We expect the Report to highlight a number of aspects where industry reform would be proposed prior to the implementation of NHI.
• The Portfolio Committee on Health has invited interested individuals and relevant stakeholders to submit written comments and indicate interest in making an oral submission on the National Health Insurance Bill, by 11 October.
• The Council for Medical Schemes (CMS) has reiterated its mandate and intent to establish a Beneficiary Registry. It states that it has been tasked by the Minister of Health to establish a central repository containing all funded (medical scheme) patients in South Africa. This registry, called the National Beneficiary Registry (NBR), will benefit the CMS and the medical schemes industry in that it would assist, among others, in verifying medical scheme membership for patients in the public sector, will provide data to assist in health planning and link to the future NHI Health Patient Registration System. CMS and the Government Employee Medical Scheme (GEMS) have concluded a pilot study pertaining to such a Registry, which proved to be extremely successful and beneficial. The CMS has now invited other medical schemes to participate in a similar pilot.
• The President has gazetted a proclamation authorising an investigation by the Special Investigating Unit, amongst others, into allegations of serious maladministration at the CMS and improper and unlawful conduct of employees of the CMS.
• In a recent Circular, the CMS provided an update on the review of the current 25% reserve requirement for all medical schemes, a process which started in 2015 and has included input from various stakeholders.

It stated in the circular that the current solvency requirement is out of line with other South African prudential requirements. Both long-term and short-term insurance environments have risk-based solvency frameworks in place.

This creates an incentive for providers of health care financing products to structure their products in such a way that they meet the definition of the product with a lower solvency requirement. One of the considerations, for levelling the playing field, is to have a regime similar to that of the Solvency Assessment and Management (SAM) Framework, which specifies capital requirements for long- and short-term insurers.

^{DISCLAIMER
Although this document has been prepared with due care and in good faith, the interpretations and opinions are those of the authors and are subject to change without notice. As such, the contents do not constitute definitive advice and should not be accepted as such. Neither ACA Employee Benefits (Pty) Ltd and Simeka Health (Pty) Ltd nor the authors accept liability for any damage whatsoever or however it may arise, including but not limited to, direct, indirect or consequential loss that may arise as a result of sole reliance on the information herein. Competent professional advice should be sought when dealing with any contentious issue. ACA Employee Benefits (Pty) Ltd and Simeka Health (Pty) Ltd is a duly authorised financial services provider.}