Benefit Accumulator
The GEMHEALTH Medical aid scheme is a closed scheme; a solidarity fund build on a concept of cross subsidisation, in which young members carry the old, the healthy carry the sick and the high income earners carry the low income members. Despite the fact it being a closed scheme, it directly competes with open schemes in benefit offering to retain.
For the past few years, members through the annual roadshow have been requesting that the scheme look at options to reward members who manage their benefits efficiently. As part of the new benefit enhancements for 2019, the Board of Trustees approved the introduction of a Namdeb Benefit Accumulator effective 01 April 2019, applicable to members registered on Option 1. Download
1. What is a Benefit Accumulator?
A benefit accumulator, is a scheme benefit which offers members the option to accumulate benefits if their total annual day to day claims are less than the allocated threshold limit .
These accumulated benefits are carried over to the following financial year and members can utilize these benefits to supplement their benefits or cater for medical services that are not covered under the scheme benefits structure. It is an option that offers members to save on their medical claims and use the accumulated benefits in the following financial years when they need it.
2. How does the Benefit Accumulator work?
- Each scheme member according to the size of their registered families, will be allocated a monetary threshold limit per annum.
- Should the member total day to day claims be less than the threshold limit, the benefit amounting to 5% of the difference between the overall annual day to day limit and the member’s actual claims in respect of day-to-day benefits (excluding chronic medicine claims) will be transferred to the member’s Benefit Accumulator Account.
- To allow for the 4-months claim cycle in which claims can be submitted to the Scheme, after the date of service, the benefit accumulator will only be carried over at the end of April of the following benefit year.
- In other words, the benefit accumulator of the 2019 financial year, will only be carried over at the end of April 2020.
3. What are threshold limits?
The threshold limit is the total maximum allowable value of claims per member that will be considered in the allocation of the benefit accumulator. The Threshold limit is allocated according to the number of registered dependents on the scheme, and the total member plus dependents total day to day claims, should be less than the stipulated threshold limit for a member to qualify for the benefit accumulator.
The Threshold limits:
| Family Size | OAL-Day to Day | Threshold Limit | % Benefit Accumulator Amount transferred |
|---|---|---|---|
| MO | 31,240 | 6,248 | 5% |
| M+1 | 62,480 | 12,496 | 5% |
| M+2 | 74,070 | 18,518 | 5% |
| M+3 | 74,070 | 22,221 | 5% |
| M+4 | 74,070 | 25,925 | 5% |
| M+5 | 74,070 | 29,628 | 5% |
Example:"}
- If the member’s total day to day claims are less than the annual threshold limit as indicated in the table above, 5% of the difference between the total day to day benefit limit and total actual member’s claim will be carried over to the following year.
- If the member’s total day to day claims exceed the threshold limit, member will not qualify for the benefit accumulator.
NB: Members can only qualify for the benefit accumulator if their total day to day claims are less than the threshold limit.
Examples: Scenario 1
| Member A: Registered member with 3 dependents: | N$ | |
|---|---|---|
| 1 | Overall day to day benefit limit for 2019: | 74,070 |
| 2 | Threshold limit applicable on the member: | 22,221 |
| 3 | Total member plus dependents total day to day claims for 2019. | 20,000 |
| 4 | Benefit Accumulator: Calculated as follows: 5% of the difference between the total Overall day to day limit, entry line 1 and members’ total day to day claims, entry line 3.) (74,070 – 20,000 = 54,070 x5%=2703.50) |
2,703.50 |
Examples: Scenario 2
| Member A: Registered member with 3 dependents: | N$ | |
|---|---|---|
| 1 | Overall day to day benefit limit for 2019: | 74,070 |
| 2 | Threshold limit applicable on the member: | 22,221 |
| 3 | Total member plus dependents total day to day claims for 2019. | 30,000 |
| 4 | Benefit Accumulator: Member did not qualify for the benefit accumulator as the total day to day claims exceed the threshold limit. |
0.0 |
4. Which benefits are considered for the Benefit Accumulator?
All benefits paid from the day to day or out of hospital benefits, excluding chronic medication and external appliances.
5. What type of claims can be paid from the Benefit Accumulator?
The Benefit Accumulator may be used for the following medical expenses list:
- Routine medical costs, even if the respective benefit has been depleted for the benefit year;
Member co-payments; - Treatment normally excluded in terms of the Scheme Rules;
- Medical and clinical treatment that is allowed in terms of the definition of a medical service as defined in the Medical Aid Funds Act. The product and/or service claimed for must be provided by a healthcare provider, registered with the Health Professions Council of Namibia (HPCNA).
- Expenses for opticians/optometrist prescribed sunglasses, protein supplements, vitamins, treatment for infertility, cosmetic procedures, etc., provided the service and/or healthcare product(s) is being supplied by a registered healthcare professional. Members should contact their nearest client service office to obtain more information.
6. What claims are not eligible to be paid from the Benefit Accumulator?
- Non-medical expenses without a valid chargeable code or NAPPI code or services provided by a non-registered medical service provider will not be covered.
- Claims for any person or beneficiary not registered as a dependent of the principal member
7. When are the accumulated benefits carried over to the following financial year?
To allow for the 4-months claims cycle in which claims can be submitted to the Scheme after the date of service. The Benefit Accumulator will only be carried over at the end of April of the following benefit year. In other words, the 2019 benefit accumulator will be carried over as from May 2020.
8. What happens to the Benefit Accumulator in an event where a main resigned, pass away or is transferred to another company within the Namdeb Scheme group participating employers?
The Benefit Accumulator will be available to the member as long as he/she is a fully paid up member of the Scheme.
- On resignation of membership, the amount in the Benefit Accumulator account will revert back to the reserves of the Scheme. It is important to note that in accordance with the Medical Aid Funds Act, no cash refunds can be paid out to a member.
- Upon the death of the principal member, any accumulated amount in the Benefit Accumulator Account due to the member shall be transferred to his/her dependents should they continue membership on the Scheme. Where the dependents of such deceased member decide to resign from the Scheme, any benefits available in the Benefit Accumulator will be transferred into the reserves of the scheme.
- Main members who are transferred from one participating employer to any other employer within the Namdeb Medical Aid Scheme Participating Employer Groups, who remain registered as a main member or dependant on the Scheme will retain their benefit accumulator.
9. How do I claim from the Benefit Accumulator?
- Members, who have benefits available in the accumulated Benefit, will be required to submit a benefit accumulator form.
- No claim for a member shall be processed from the Benefit Accumulator Account without the submission of a claim form, the principal member need to authorize all claims to be paid from the benefit accumulator account.
- Planned procedures and or optical benefits may be paid directly to the respective Healthcare
10. Where can I obtain a Benefit Accumulator claim form:
- The benefit Accumulator claim form can be obtained at any Prosperity Client service offices and it will also be available on the Namdeb Scheme website.
- If in doubt and a member wish to ensure that a claim will qualify for payment from the Roll-over or Accumulator Account members can enquire and request an authorization from the administrators