Unzalaru medical scheme

Presentation

Done by Chowa (PhD)

Livingstone 2017
 Unzalaru medical scheme
Owners managed scheme Administered
• Captive • Example -AON
• Self managing • Pure medical aid
• Surplus and deficit • Taking market rates
• Surplus –Investment • Employer contribution
• Deficit – management • Tax deductable
 Major medical cover
Hospitalization Reinsurance

• Insurance • Some procedure cost can be

reinsured
• Group schemes- healthy
people or cross
subsidization
• Equity –and cross
subsidization challenges
Challenges of setting up of scheme
Internal controls Choices of service providers
• Members control • Medical attention without
• Hospital controls waiting
• Policy document • High standard of
• Referral system accommodation
• Limits
• Doctor of choice
• Authorization
• Benefits • Proximity to area of
• Co-payments residence
• Unzalaru basic and executive
options
 Sustainability of scheme
Sustainability issues by private
Key indicators scheme

• Cost reflective • Waiting period ( impose

• Quality vs Quantity waiting period of 3 months
before service access)
• Credibility • May underwriting and
• Self refinancing acceptance
• Indemnity • Joining the scheme because
• Member retention of anticipated situation
• Recruitment • Age limits
• Choice limits
• Law
• Co payments
 Sustainability of scheme
Group Schemes best practice
• Eligibility
• Policy conditions
• Cost sharing
• Pre authorization
• Hospital bands and network
• Negotiate the best package
with hospitals ( nature of
duty of members as bargain
unit)
 Starting the scheme
Financing requirement Indicators of good scheme

• Endowment fund • 80% should cover person

• Minimum capital:3-4 month
cover even if there is no
contribution
• Reserve building
• Design the benefits
• 10% operation cost
• Common pool
• Rights and expectation of
scheme holders
 Service Level agreement
Stakeholders Diligence

• The service provider list and • Delivery to expectation

member expectations • Costs
• Quality
• UNZA management –funds • Expertise
• Hospitals • Doctor’s database
• Clinics • Diversification across other
stakeholders
• Labs • Limits on
• Reinsurance –insurance stakeholders/counterpart
exposure
riders • Setting of floors and ceiling on
stakeholders
 Service Level agreement
Stakeholders/ Counterpart
• Possibility of bed-
reinsurance
• Add other cover products(
insurance policy)