Scrutiny persists over NHP’s shift to Universal Care

The standard tariffs of the Namibia Association of Medical Aid Funds (Namaf) remain the benchmark for processing claims and administering benefits for the Namibia Health Plan (NHP), in line with the country’s healthcare framework and the fund’s rules.

NHP was responding to allegations by private healthcare providers that codes aligned with Namaf tariffs are not being recognised by its new South African administrator, Universal Care.

NHP principal officer Dantago Garosas told Namibian Sun’s sister publication, Republikein, this week that the fund continues to work with Universal and stakeholders to resolve coding alignment issues, to ensure approved treatment continues and minimise any administrative disruptions to patient care.

Referring to claims that treatment plans for patients currently receiving care are being rejected, Garosas said claims are not simply declined outright.

“All clinical funding decisions are evaluated in accordance with the fund’s rules, members’ entitled benefits and established clinical protocols,” she said.

She said the fund remains committed to protecting members’ wellbeing, maintaining continuity of medically necessary treatment, and ensuring all funding decisions are fair, transparent and aligned with regulatory and clinical governance standards.

Asked to respond to serious concerns raised by service providers over the protection of patients’ information, as well as the financial security of patients and providers, Garosas stressed that these issues are fundamental to NHP’s governance and operational mandate.

“NHP continues to actively monitor service delivery, engage with stakeholders and address industry issues as they arise. This is to ensure members’ interests and regulatory obligations remain fully protected,” she said.

Concerns mount

Several complaints have been received regarding difficulties service providers face in registering on the Universal network. These include concerns that certain plans and options are not applicable in Namibia, that fees do not correspond with Namaf tariffs, that coding rules are not aligned with Namaf standards, and that several codes and treatments are being excluded by Universal as the fund’s new administrator.

It is further alleged that service providers who sign the agreement are bound by restrictive codes and fees that do not align with Namaf standard tariffs.

As a result, no other tariff codes or fees prescribed by Universal would reportedly be paid out.

Garosas, however, said service providers are not required to participate in “any inappropriate tariff framework that is not aligned with the Namibian healthcare environment”.

“Provider network arrangements are structured to operate within the Namibian regulatory framework, including applicable Namaf tariffs and fund rules,” she stressed.

In an earlier statement, NHP said its rules had not changed. Service providers, however, say no clarity has been provided regarding Universal Care’s Namibian ownership structure or its registration with the Business and Intellectual Property Authority (Bipa).

Responding to these concerns, Garosas emphasised that NHP’s rules had not changed as a result of the transfer to a new administrator.

“Universal Care is an external service provider appointed by the fund through a formal contractual agreement," she said.

“This follows thorough due diligence and operates within a framework of ongoing oversight to ensure compliance with applicable governance, regulatory and contractual standards,” she added.

Fima regulations

Questions have also been raised over whether NHP’s transition to Universal complies with the Financial Institutions and Markets Act (Fima), which came into force this month.

Concerns have specifically been expressed about whether the fund’s transition is in line with the law’s provision that the core functions of a medical fund, including claims assessment, healthcare payments and benefit design, must be managed in Namibia under the supervision of the Namibia Financial Institutions Supervisory Authority (Namfisa) and may no longer be outsourced.

According to Garosas, NHP is compliant with Fima.

“NHP operates within this regulatory framework and remains subject to Namfisa’s ongoing oversight and compliance requirements,” she said.

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