BENEFIT GUIDE 2020 - My · New Generation Options – New Generation Options – the new generation options, Emerald and Amber, cater for comprehensive hospital cover. New options,

BENEFIT GUIDE 2020

MEMBER COMMUNICATION 3 TOPAZ & TOPAZ PLUS 8OPAL & JADE 16 RUBY & SAPPHIRE 25EMERALD & AMBER 36EMERALD PLUS & AMBER PLUS 41

MEMBER COMMUNICATION

Dear Member,

As the curtain comes down on 2019, we would like to thank you for your support. We continue to do our very best to ensure you get the quality care during your time of need and are always looking at ways in which we can better serve you.

ACCESSIBLEINFORMATION/DOWNLOADS

The benefits pricing guide is now available for download – please visit our website, www.nmcfund.com to download the electronic file as well

as access other important 2020 documents. Please send an e-mail to [email protected] should you not have access to the internet or you are unable to open or download these documents, and we will gladly e-mail the electronic files to you.

HIGHLIGHTS 2019

• Solvency ratio of 49%.• Healthy reserve level of 29.1%• Membership growth of 1%• The Fund continued to honour claims and award assistance through the ex gratia programme.

PREMIUM CONTRIBUTIONS

Although the Fund aims to keep the annual increase as low as possible, it is necessary to implement an increase to ensure that the Fund remains in a position to cover medical claims sufficiently according to the benefit structure and to cover costs related to medical inflation, tariff increases and benefit adjustments. The average premium increase for 2020 is 6.5% for groups and 6% for individual members. Contribution tables for the Diamond and Sapphire options have been restructured to a Member/Adult/Child basis. The single

parent reduction in premiums will remain at 12.5% in the total contribution of single parents with children as dependants on their membership on the Ruby option.

Two new generation options have been introduced to cater to the needs of members who require day-to-day benefits for out-of-hospital expenses on their comprehensive hospital plan. The new options replace the savings options, which were phased-out following a directive by the regulator, NAMFISA in 2018.

BENEFIT OPTIONS

Traditional Options – there are seven traditional options that cater from entry-level to comprehensive benefits. The traditional options are Diamond, Sapphire, Ruby, Jade, Opal, Topaz Plus and Topaz. Please refer to the 2020 Member Guide for the detailed benefits and contributions on each option.

New Generation Options – New Generation Options – the new generation options, Emerald and Amber, cater for comprehensive hospital cover. New options, “Amber Plus” and “Emerald Plus” were introduced to cater to the needs of members requiring day-to-day benefits, 95% of the unused benefits will “roll-over” to the next year. Please refer to the 2020 Member Guide on the detailed explanation on Emerald and Amber’s benefits.

BENEFIT ADJUSTMENTS 2020

Inflationary increases were made on most of the benefits, with significant improvement on the following benefits:• Insulin pump and consumables benefit limit for

Diamond, Sapphire and Ruby options.• A standalone benefit for Primary health care on

Opal, Jade, Ruby, Sapphire, Diamond, Emerald Plus & Amber Plus.

• A separate benefit for lifestyle management for various screenings.

• All-inclusive (in and out-of-hospital) limited benefit for Oncology.

• Ante-natal and post-natal benefit added to the maternity benefit.

Please refer to the options section for detailed benefits.

IMPORTANT INFORMATION

Option Change: Members can only change their option once a year, during the month of January (unless a member changes employment or there is a change in marital status). If you would like to upgrade to a more comprehensive option or if you intend on downgrading, kindly ensure that you complete the Option Change Form (enclosed). The completed form must reach the Fund on or before 15 January 2020. Completed forms can be submitted to any of the Methealth offices across the country, faxed to (061) 287 6049 or e-mailed to [email protected]

Update of Bank Account and Personal Details: The Fund requires that you provide us with your up-to-date banking details for Electronic Fund Transfers (“EFT”) to ensure speedy settlement of your claims or debit order deduction of your monthly premiums should this not be done via your employer. Also kindly provide your updated postal address, physical address, cell phone number, e-mail address and telephone number in order for us to update your data on the medical aid system. Please download the member record amendment form available on our website, www.nmcfund.com.

Opal Members: Members who are registered on Opal are restricted to a maximum gross income of N$ 14 660. Members who have reached the maximum gross income bracket will be required to select any of the other options. Jade is the best suitable option after Opal.

Kindly ensure that your employer provides NMC with your gross salary details as at 01 January 2020 should you be on the Opal option. This will ensure that you make the correct contributions according to the income categories of the Opal option.

For further details please contact one of our Methealth Offices or visit our website, www.nmcfund.com.

Namibia Medical Care | 2020 Benefit Guide 3

ADDITIONAL BENEFITS AND SERVICES OFFERED BY NMC FOR 2020 AT NO ADDITIONAL COST

1. International Medical Travel InsuranceThe International Medical Travel Insurance makes provision for emergency medical expenses whilst NMC members and/or their dependants are travelling. The cover is limited to N$ 10 million per incident and up to a maximum of 90 days per trip and 180 days in total per annum in a foreign country. The International Medical Travel Insurance does not apply to any non-emergency and planned elective surgery or procedure. This benefit is not applicable to Topaz Plus and Topaz members. Apply for your travel certificate before you embark on your trip.

2. Emergency EvacuationThe Fund offers emergency air and road ambulance evacuation services to NMC members. All authorised air ambulance flights and long-distance road ambulance transport services are covered. The cover provides the best possible, most effective and efficient emergency evacuation services. All emergency services for life-sustaining conditions that require emergency transport are covered.

3. Premium WaiverThe Premium Waiver benefit covers a member’s premiums for 3 (three) months in the event of the principal member passing away, on condition that the members are fully paid-up on their monthly premium. This benefit is not applicable to Topaz Plus and Topaz members.

4. Special Premium for Single ParentsThe special premium for single parents was implemented to lighten the financial burden of single parents. A 12.5% reduction is awarded on the total contribution of single parents with children as dependants on the Ruby option.

5. Benefit BoosterThe Benefit Booster is a supplementary benefit on certain day-to-day medical services where the overall

annual limits have been exceeded. Should a member or a dependant’s day-to-day benefit limit on General Practitioner, Specialist, Medicine (self-medication excluded), Primary Healthcare, Dentistry, Auxiliary and Out-of-Hospital casualties be depleted, the Benefit Booster will automatically take effect. The Benefit Booster is only applicable to the Diamond, Sapphire, Ruby, Jade and Opal options.

6. Additional Hospital Benefit Cover (AHB)AHB Cover pays (from the first dollar) the excess of NAMAF tariff for General Practitioners and/or Specialists should a member/dependant be hospitalised. Hospitalisation can be traumatic, unexpected and expensive and, NMC therefore, believes that AHB will be of immeasurable financial value when our members need it most. NMC pays 100% of NAMAF tariff PLUS a maximum of 125% additional cover for any excess of the NAMAF tariff that General Practitioners and Medical Specialists may charge.

7. Ex Gratia PolicyEx gratia is an additional grant from the Board of Trustees, approved on certain criteria for unexpected major medical expenses and costs outside the scope of benefits of NMC.

8. Hospital Bedside Support ServicesNMC offers specialised supportive bedside assistance for members in hospital through a daily visit by the Patient Care Co-ordinator. The Patient Care Co-ordinator also keeps in touch with the member’s family when necessary by providing information on the particular illness of the member. This service is part of NMC’s drive towards its members’ overall wellbeing.

9. HIV/AIDS Outreach ProgrammeNMC recognises the importance of HIV/AIDS positive members to be sufficiently covered for uninterrupted treatment and healthcare management. Provision of HIV/AIDS benefits on ALL options has therefore been made and provide members with peace of mind that they will not run out of benefits during the year. The Namibian-

owned HIV/AIDS Disease Management Programme is administered by MyHealth Administrators. The programme is managed by qualified HIV/AIDS Case Managers, HIV Counsellors and a Medical Advisor who provides monitoring, support and total confidence to members who are HIV positive.

10. Lifestyle Management Programme

NMC is proud to continue making a difference in the lives of our members through the NMC Lifestyle Management Programme. The Lifestyle Management Programme offers the following:

• Healthy Lifestyle Programme for Individuals• Corporate Lifestyle Management Programme• The Walking Club (provided by the Administrator,

Methealth) • Online Healthy Lifestyle Challenges from the

comfort of your home (refer to https://nmcfund-challenges.com/ for more information)

• Participation in social runs in conjunction with Windhoek City Runners.

A CLIENT SERVICE OFFICE IN YOUR AREANMC has the biggest branch network in Namibia with offices in:• Windhoek (Maerua Office Park & Central Branch

(MMI House))• Swakopmund• Walvis Bay• Oshakati• Tsumeb • Keetmanshoop • Rosh Pinah • Oranjemund • Lüderitz• Ondangwa • Rundu

4 Namibia Medical Care | 2020 Benefit Guide

CLIENT SERVICES CONTACT DETAILS

Methealth (Head Office) Methealth Office ParkMethealth (Head Office)

Methealth Office ParkPhone: (061) 287 6000/6001/6006/6061Fax (061) 287 6091E-mail: [email protected]

For Health ProfessionalsEmail: [email protected]

MMI HousePhone: (061) 297 3222Fax: (061) 294 7352E-mail: [email protected]

Walvis Bay BranchPhone: (064) 200 563/200 276/200 253Fax: (064) 200 376E-mail: [email protected]

Swakopmund BranchPhone: (064) 402 529Fax: (064) 405 235E-mail: [email protected]

Tsumeb BranchPhone: (067) 221 767Fax: (067) 222 812E-mail: [email protected]

Lüderitz BranchPhone: (063) 203 525Fax: (063) 203 561E-mail: [email protected]

Oshakati BranchPhone: (065) 220 774 / 177Fax: (065) 220 779E-mail: [email protected]

Rundu Branch Phone: (066) 255 035 / 267 344Fax: (066) 255 [email protected]

Ondangwa BranchPhone: (065) 240 409Fax: (065) 240 155Fax: (063) 234 146Email: [email protected]

Rosh Pinah BranchPhone: (063) 274 901Fax: (063) 274 902E-mail: [email protected]

Oranjemund BranchPhone: (063) 234 140Fax: (063) 234 146Email: [email protected]

It is our aim to keep supporting you as you continue to achieve your goals and live your life to the fullest. We wish you a happy holiday and a new year filled with health, happiness, and success.

The PO & TrusteesNamibia Medical Care


LIFESTYLE MANAGEMENT PROGRAM

The Lifestyle Management program is a program designed to assist members to improve lifestyle choices to prevent or reduce the progression of chronic diseases as well as counselling to prevent health problems.

Taking a holistic approach into consideration the Lifestyle Management aims to understand how people can change unhealthy habits into healthy habits by:

• Reducing the risk of heart attack, stroke, diabetes, cancer and many other preventable chronic diseases

• Optimise fitness• Achieve and maintain a healthier weight• Improve blood pressure and cholesterol values• Manage stress better• Improving one’s mental health • Stop using tobacco• Choose healthier foods• Master other health issues important to individuals• Immunizations can help you and your family stay

healthy.

In addition, the Lifestyle Management programme continues to bring routine medical check-ups directly to our members. The Corporate Lifestyle Management programme is amongst the most vital investments that an employer can make – this enables the employers to invest in the physical and mental wellbeing of their employees.

How to Book a Lifestyle Management Day • An employer group contacts the Lifestyle

Management department and requests a corporate lifestyle screening.

• Appointment/dates are scheduled to ensure maximum staff attendance.

• The Lifestyle Management team will go to the employer group and perform the basic general screenings: random glucose, random blood cholesterol, blood pressure, weight, waist circumference and calculate the Body mass index (BMI).

During the screenings each member will receive a full consultation on their results; and if any health irregularities are identified, the following procedure is followed: • Referral from the Lifestyle management department

to see a dietician or biokineticist. • Referral to a general practitioner for medication

management. • Health advice is given to staff with regards to healthy

lifestyle choices and exercises.

The vision of the Lifestyle Management team is to continuously provide members and employer groups with relevant information on healthy lifestyle choices, how to effectively manage your benefits and with the aid of health professionals to assist in accomplishing a healthier lifestyle and create awareness on mental health and other health related issues.

The Lifestyle management team also hosts open days for small groups and individual members at shopping malls, dates are communicated via our social media platforms. Our intention is to provide this service to all regions annually on a rotational basis.


DISCIPLINE EMERGENCY EVACUATION PROVIDER EMERGENCY CONTACT NUMBER MAIN AREA OF COVERAGE % NAMAF TARIFF COVER

ALS AEMS Ambulance Services 081 963 Windhoek & Surrounding Areas 100%

ALS City of Windhoek Emergency Services 061 211 111 Windhoek & Surrounding Areas 100%

ALS Code Red Medical Services 085 99 00085 705 8940 (from cell)

Coast (Arandis, Walvis Bay, Swakopmund &Henties Bay) or as per request

100%

ALS Crisis Response 085 99 00085 705 8940 (from cell)

Coast (Arandis, Walvis Bay, Swakopmund &Henties Bay) or as per request

100%

ALS Okahandja Paramedical Services 987 Okahandja & Surrounding Areas 100%

ALS Lifelink Emergency Services 999 (from any landline)085 900 (from cell)

Windhoek & Long Distance Countrywide 100%

ECT Mr 24/7 085 956(061) 255 676

Rehoboth, Windhoek, Otjiwarongo, Tsumeb &Mercy Flights Countrywide

100%

ALS + ILS Namibia Private Ambulance Services 081 9696 Outapi, Ongwediva Rundu & Ondangwa &Long Distance Countrywide

100%

ECT Intensive Therapy Unit Ambulance Services 081 444 7807 Eenhana & Long Distance Countrywide 100%

ILS + ECT Outapi Ambulance 065 251 022/ 251 800 Outapi, Oshakati & Surrounding Areas 100%

ILS Ohangwena Private Ambulance Services 081 9797 Grootfontein, Windhoek, Katima & Tsumeb 100%

ILS Ondangwa Ambulance Services 081 90 200 Ondangwa & Countrywide 100%

ILS Rosh Pinah Clinic Ambulance Service 063 274 918/081 161 8734

Rosh Pinah & Oranjemund 100%

ILS St. Gabriel Community Ambulance Trust 085 955/ 081 124 5999 Walvis Bay & Swakopmund 100%

ALS E-Med Rescue 24 081 924 All Major Cities & Air Ambulance Evacuation Countrywide

100% (Members to Pay Cash Up front, and Claim a Refund)

ALS - Advanced Life Support Service ILS - Intermediate Life Support Service ECT - Emergency Care Support Technician Service

In case of an emergency dial 112 (the international mobile phone SOS number).

EmergencyEvacuation/Ambulance Providers Namibia

OVERALL ANNUAL BENEFIT(OVERALL ANNUAL LIMIT)

TOPAZ TOPAZ PLUSUnlimited According to Defined Primary Healthcare Protocols

CATEGORY A: Primary Healthcare Benefits % Tariffs

1. Nurse

100%

Registered Nurse Registered Nurse

1.1. Consultations / Visits Unlimited Unlimited

1.2. Medication / InjectionsUnlimited

(According to Topaz & Topaz Plus Medicine Formulary)

Unlimited. (According to Topaz and Topaz Plus Medicine Formulary)

1.3. Procedures Unlimited Unlimited

2. General Practitioner

100%

According to defined protocols According to defined protocols

2.1. Consultations / Visits (Out-Of-Hospital) Unlimited(0101 & 0108 only) Unlimited

2.2. Acute Medication / Injections(Paid at Maximum Namibia Medicine Price on generics)

(According to Topaz and Topaz Plus Acute Medicine Formulary) (According to Topaz and Topaz Plus Acute Medicine Formulary)

2.3. Chronic Medication/Injections - Subject to Chronic Medication Registration

(Paid at Maximum Namibia Medicine Price on generics)

(According to Topaz and Topaz Plus Chronic Medicine Formulary) (According to Topaz and Topaz Plus Chronic Medicine Formulary)

2.4. Procedures (out-of-hospital) UnlimitedAccording to defined protocols No Benefit

3. Medical Specialists Consultations / Visits No Benefit 5 per Family per annum(0101 and 0108 only)

4. Pharmacy 100% Unlimited Unlimited

4.1. Acute Medication / Injections(Paid at Maximum Namibia Medicine Price on generics)

100%

(According to Topaz and Topaz Plus Acute Medicine Formulary) (According to Topaz and Topaz Plus Acute Medicine Formulary)

4.2. Chronic Medication / Injections - Subject to Chronic Medication Registration

(Paid at Maximum Namibia Medicine Price on generics)

(According to Topaz and Topaz Plus Chronic Medicine Formulary) (According to Topaz and Topaz Plus Chronic Medicine Formulary)

5. Pathology Specified Tests Specified tests

6. Radiology 100%Long bones, chest and trauma and basic radiology as per

defined list(Excluding MRI & CT Scan)

Long bones, chest and trauma and basic radiology as per defined list

(Excluding MRI & CT Scan)


7. Dentistry 100% Extractions and Fillings Only Extractions, fillings & 2 oral hygiene visits per beneficiary including pain and sepsis as per defined list.

8. Optical 100% No BenefitN$1 000 per beneficiary every two years (2019/2020)

(6 months waiting period, complete test, specified frames and lenses)

8.1. Single Vision (Inclusive of Test, Frame and Lenses

100%

No Benefit Sub-limit 8

8.2. Bifocal (Inclusive of Test, Frame and Lenses)(Paid at Maximum Namibia Medicine Price on generics)

No Benefit Sub-limit 8

9. Sonar Scans 3 scans per Beneficiary per pregnancyGroups have cover from date of joining

Individuals have 9-month waiting period

3 scans per Beneficiary per pregnancy Groups have cover from date of joining

Individuals have a 9-month waiting period

10. Ante-natal Consultation (General Practitioner) 100%

Limited to 6 consultations per Beneficiary(2601 & 2602)

Groups have cover from date of joining Individuals have 9-month waiting period

Limited to 6 consultations per Beneficiary (2601 & 2602)

Groups have cover from date of joiningIndividuals have a 9-month waiting period

11. Paramedical / Allied Health Professionals (Psychologists, Physiotherapists, Occupational Therapists)

100% No Benefit 3 consultations / sessions per Family per annum

CATEGORY B: HIV/AIDS Treatment % Tariffs Unlimited According to Defined ProtocolsBenefits available only at Network Health Professionals

12. HIV/AIDS Treatment

100%

As per National Guidelines for Antiretroviral Therapy As per National Guidelines for Antiretroviral Therapy

12.1. Consultations (General Practitioners) 6 consultations per beneficiary (including the first full HIV consultation) Unlimited

12.2. Medication (including vitamins & supplements)

Unlimited(According to Topaz and Topaz Plus HIV Medicine

Formulary)(Vitamins & supplements maximum of N$100)

Unlimited(According to Topaz and Topaz Plus HIV Medicine

Formulary)

12.3. Pathology Unlimited Unlimited

12.4. Counselling (pre-, post & adherence) 3 Sessions 3 Sessions

12.5. Post Exposure Prophylaxis (PEP) (Rape Cover only) As per National Guidelines for Antiretroviral Therapy As per National Guidelines for Antiretroviral Therapy

12.6. Pre-Exposure Prophylaxis (PrEP) No Benefit No Benefit

12.7. Prevention of Mother-to Child Transmission (PMTCT) (excluding milk formula) As per National Guidelines for Antiretroviral Therapy As per National Guidelines for Antiretroviral Therapy


CATEGORY C: Hospitalisation Benefit Private Wing of State Hospital Private Hospitalisation

Benefits available at Network Health Professionals

Planned procedures: waiting period of 6 months after joining: Emergency cases: immediate cover

Overall Annual Limit % Tariff Unlimited

N$115 000 per familyPre-authorisation: 100% of tariff will be paid out.

Without Pre-authorisation: No benefit will be paid out except in the case of emergency hospital admissions and emergencies after-hours, weekends and public

holidays.

13. Hospitalisation

100%

13.1. Accommodation and Theatre Overall Annual Limit Overall Annual Limit15 days per Beneficiary

13.2. Blood Transfusions Overall Annual Limit Overall Annual Limit

13.3. Intensive and High Care (3 days then referral to State Hospitals) Overall Annual Limit Overall Annual Limit

13.4. Medicine, Fixed Tariff Procedures, Hospital Apparatus and To Take Out Medicine Overall Annual Limit Overall Annual Limit

(Limited to 7 days’ supply only)

13.5. Radiology & Pathology (In-Hospital) Sub-limit 14 N$3 000 per Family Sub-limit 14

14. General Practitioners & Medical Specialists (In-Hospital services)

- Additional Hospital Benefit Cover excluded100% N$25 000 per Family

Overall Annual Limit

N$25 000 per Family(Including Radiology and Pathology)


15. Other Healthcare Providers 100% No Benefit No Benefit

16. Maternity

Unlimited Hospitalisation in State Hospital (GPs and Specialists limited to Sub-Limit 14)


Unlimited Hospitalisation in State Hospital(GPs and Specialists limited to Sub-Limit 14)

Groups have cover from date of joiningIndividuals have a 9-month waiting period.

17. Ambulance Services

100%

Unlimited Unlimited17.1. Emergency Road Ambulance* (Territory: SADC Countries)(Subject to pre-approval)

17.2. Ambulance/Inter-hospital Transfer* (Subject to pre-approval) N$550 per Family N$550 per Family


Contribution Tables

Topaz Individual Contributions Topaz Plus Individual Contributions

Main Adult Child Age Band Main Adult Child

591 522 183 0 35 804 665 236

36 60 1,071 886 315

Topaz Group Contributions Topaz Plus Group Contributions

Main Adult Child Age Band Main Adult Child

438 377 144 0 35 665 548 195

36 60 886 731 260

Topaz Plus Student Contributions

Main

527

Detailed Benefits:

These rules apply for Topaz and Topaz Plus

Service Availability

Please note that all benefits on Topaz and Topaz Plus are only available through registered TopazNetwork Health Professionals.

Please visit our website at www.nmcfund.com for the updated Topaz Network Health Professionals list.

Pathology

The following tests are pre-approved and can be done at the discretion of the treating general practitioner:

TARIFF CODE (052)

TARIFF CODE (037) TARIFF DESCRIPTION

3755 53755 Full blood count

3792 53792 Plasmodium falciparum: Monoclonal immunological identification

3797 53797 Platelet count

TARIFF CODE (052)


3816 53816 T and B-cells markers (per marker)

3865 53865 Parasites in blood smear

3869 53869 Faeces: including parasites

3883 53883 Concentration techniques for parasites

3885 53885 Cytochemical stain

3932 53932 Antibodies to HIV: Elisa (Note: HIV-DNA PCR is excluded)

3951 53951 Quantitative Kahn, VDRL or other Flocculation

3999 53999 Albumin

4001 54001 Alkaline phosphatase

4006 54006 Amylase

4009 54009 Bilirubin: Total

4027 54027 Cholesterol: Total

4032 54032 Creatinine

4057 54057 Glucose: Quantitative

4113 54113 Potassium

4117 54117 Protein: Total

4131 54131 Alanine aminotransferase (ALT)

4134 54134 Gamma glutamyl transferase (GGT)

4155 54155 Urine acid

4161 54161 Troponin isoforms: each

4182 54182 Quantitative protein estimation: nephelometer or Turbidometeric method

4429 54429 Quantitative PCR (DNA/RNA) (Note: only for HIV management and according to National Guidelines )

4450 54450 HCG: Monoclonal immunological: Qualitative

4519 54519 Prostate specific antigen

4531 54531 Hepatitis: per antigen or antibody (Maximum of 3 Antigens)

4610 54610 Helicobacter pylori stool antigen test

Other Pathology tests are excluded.

*Pending approval by the Registrar of Medical aid Funds in Namibia/NAMFISA Namibia Medical Care | 2020 Benefit Guide 11

Radiology

Topaz and Topaz Plus are limited to basic radiology: Essentially long bones; CXR; trauma excluding MRI and CT Scans. Referral from treating General Practitioner only. The following procedures are covered:


10100 X-ray of the skull

11120 X-ray of the nasal bones

14100 X-ray of the mandible

20100 X-ray of soft tissue of the neck

30100 X-ray of the chest, single view

30110 X-ray of the chest two views, PA and lateral

30120 X-ray of the chest complete with additional views

30150 X-ray of the ribs

30155 X-ray of the chest and ribs

34200 Ultrasound study of the breast

40100 X-ray of the abdomen

40105 X-ray of the abdomen supine and erect, or decubitus

40110 X-ray of the abdomen multiple views including chest

40210 Ultrasound study of the whole abdomen including the pelvis

51110 X-ray of the cervical spine, one or two views

51120 X-ray of the cervical spine, more than two views

53110 X-ray of the lumbar spine, one or two views

53120 X-ray of the lumbar spine, more than two views

55100 X-ray of the pelvis

56100 X-ray of the left hip

56110 X-ray of the right hip

56120 X-ray pelvis and hips

61100 X-ray of the left clavicle

61105 X-ray of the right clavicle

61110 X-ray of the left scapula

61115 X-ray of the right scapula

61120 X-ray of the left acromio-clavicular joint

61125 X-ray of the right acromio-clavicular joint

61130 X-ray of the left shoulder


61135 X-ray of the right shoulder

62100 X-ray of the left humerus

62105 X-ray of the right humerus

63100 X-ray of the left elbow

63105 X-ray of the right elbow

64100 X-ray of the left forearm

64105 X-ray of the right forearm

65100 X-ray of the left hand

65105 X-ray of the right hand

65120 X-ray of a finger

65130 X-ray of the left wrist

65135 X-ray of the right wrist

65140 X-ray of the left scaphoid

65145 X-ray of the right scaphoid

71100 X-ray of the left femur

71105 X-ray of the right femur

72100 X-ray of the left knee one or two views

72105 X-ray of the right knee one or two views

72110 X-ray of the left knee, more than two views

72115 X-ray of the right knee, more than two views

72120 X-ray of the left knee including patella

72125 X-ray of the right knee including patella

72150 X-ray both knees standing - single view

73100 X-ray of the left lower leg

73105 X-ray of the right lower leg

74100 X-ray of the left ankle

74105 X-ray of the right ankle

74120 X-ray of the left foot

74125 X-ray of the right foot

74130 X-ray of the left calcaneus

74135 X-ray of the right calcaneus

74140 X-ray of both feet - standing - single view

74145 X-ray of a toe


Sonar Scans

Pregnancy ultrasounds are limited to 3 sonars per beneficiary per pregnancy. The following procedures are covered:


43250 Ultrasound study of the pregnant uterus, first trimester

43260 Ultrasound study of the pregnant uterus, second trimester

43270 Ultrasound study of the pregnant uterus, third trimester, first visit

43273 Ultrasound study of the pregnant uterus, third trimester, follow-up visit

Dentistry*

Topaz basic dentistry includes extractions and fillings only. The following procedures are covered:

TARIFF CODE (054)


8101 001 Consultation

8104 004 Examination for a specific problem

8107 005 Intra-oral radiographs, per film,

8109 009 Infection Control

8110 066 Sterile tray

8145 040 Local Anaesthetic

8201 025 Extraction 1st tooth

8202 027 Extraction 2nd tooth

8341 051 Amalgam – one surface

8342 052 Amalgam – two surface

8343 053 Amalgam – three surface

8344 054 Amalgam – four or more surface

8351 055 Resin – one surface, anterior

056 Resin – two surface, anterior

061 Resin – three surface, anterior

063 Resin – four or more surfaces, anterior

8352 Filling front tooth (small)

TARIFF CODE (054)


8353 Filling front tooth (medium)

8354 Filling front tooth (large)

Topaz Plus basic dentistry includes extractions, fillings and two oral hygiene visits per Beneficiary, including basic dentistry specific for pain and sepsis treatment. The following procedures are covered:

TARIFF CODE (054)


8101 001 Consultation

8104 004 Examination for a specific problem

8107 005 Intra-oral radiographs, per film,

8109 009 Infection Control

8110 066 Sterile tray

8145 040 Local Anaesthetic

8155 016 Polishing only

8159 015 Scaling

8161 018 Fluoride treatment

8163 019 Fissure sealant – per tooth

8201 025 Extraction 1st tooth

8202 027 Extraction 2nd tooth

8232 Full upper or lower dentures

8233 Partial denture, one tooth

8234 Partial denture, two teeth

8235 Partial denture, three teeth

8236 Partial denture, four teeth

8237 Partial denture, five teeth

8238 Partial denture, six teeth

8239 Partial denture, seven teeth

8240 Partial denture, eight teeth

8341 051 Amalgam – one surface

8342 052 Amalgam – two surface


TARIFF CODE (054)


8343 053 Amalgam – three surface

8344 054 Amalgam – four or more surface

8351 055 Resin – one surface, anterior

056 Resin – two surface, anterior

061 Resin – three surface, anterior

063 Resin – four or more surfaces, anterior

8352 Filling front tooth (small)

8353 Filling front tooth (medium)

8354 Filling front tooth (large)

HIV/AIDS

A. Treatment - Unlimited: According to the National Guidelines for Antiretroviral Therapy.B. Counselling – 3 sessions Pre, Post and Adherence.C. Pathology – Baseline and monitoring laboratory tests as detailed in the National Guidelines

for Antiretroviral Therapy excluding HIV resistance testing. D. Rape Cover – Covered according to the defined protocol in the National Guidelines for

Antiretroviral Therapy.• Tenofovir (300 mg) plus Lamivudine (300 mg) fixed dose combination daily, Plus

Lopinavir/ritonavir combination BD for 28 days• For children – ABC / 3TC and LPV/r as an alternative when ABC cannot be tolerated.

The children over 6 years and at least weigh 5 kg and above can be given ATV/r as an option.

• Plus other supportive actions as detailed in the above guidelines.

Optical*

Six-month waiting period with a pair of glasses on every two years per Beneficiary. A pair of glasses will consist of an eye test, specified frames, non-glass lenses or non-glass bifocal lenses.

Paramedical / Allied Health Professionals*

Limited to three sessions per family, per annum. Paramedical includes services by a Psychologist, Physiotherapist and Occupational Therapist.

Medical Specialist Consultations*

Limited to five consultations per family, per annum. Requires pre-approval.

Medicine Formulary

Topaz and Topaz Plus only covers medication as specified in the Acute, Chronic and HIV Medicine Formulary available from our website: www.nmcfund.com.

*Applies to Topaz Plus only.


LIFE IS FULL OF CHOICESThe choices you make can change your life, so it’s important to make the right ones. Choose the medical aid with the widest range of options and be sure to find the perfect one for your future.

View our full product listing at www.nmcfund.com

A: Turn around

B: Keep going


OPAL JADEN$456 500 per Beneficiary

N$685 000 per FamilyN$705 000 per Beneficiary

N$1 090 000 per Family

CATEGORY A: Hospital Benefit % NAMAF Tariff

Pre-authorisation: 100% of tariff will be paid out.Without Pre-authorisation: No benefit will be paid out except in the case of emergency hospital

admissions and emergencies after-hours, weekends and public holidays.

Additional Hospital Benefit Cover: GP’s and Specialist’s in-hospital services are paid up to a maximum of 225% of NAMAF Tariff

COVER1. Hospitalisation Overall Annual Limit Overall Annual Limit

1.1. Accommodation & Theatre 100% Sub-limit 1 Sub-limit 1

1.2. Accommodation in Private Ward(Difference between general ward and private ward tariffs)

100% No BenefitLimited to N$5 000 per Beneficiary and N$ 10 000

per FamilySub-limit 1

1.3. Accommodation Other than a Recognised Hospital/Medical Institution(Subject to Prior Approval & Accommodation Expenses Reimbursement Policy)

100% of CostLimited to N$600 per day per Family

(Maximum of 2 days)Sub-limit 1

Limited to N$600 per day per Family(Maximum of 2 days)

Sub-limit 1

1.4. Blood Transfusions 100% Sub-limit 1 Sub-limit 1

1.5. Intensive and High Care (Maximum 3 days, then motivation) 100% Sub-limit 1 Sub-limit 1

1.6. Medicine, Fixed Tariff Procedures, Hospital Apparatus and To Take Out Medicine (7 days supply only)

100% Sub-limit 1 Sub-limit 1

1.7. Radiology & Pathology (In-Hospital) - Additional Hospital Benefit Cover Excluded 100% Sub-limit 1 Sub-limit 1

2. Specialised Radiology Procedures (In & Out Of Hospital)Additional Hospital Benefit Cover Excluded

- Referral from a medical specialist only (referral from GP acceptable in places where there is no medical specialist) (Subject to prior approval)

100% Overall Annual Limit Overall Annual Limit

2.1. MRI & CT Scans 100% N$12 000 per Family Sub-limit 2

N$14 000 per FamilySub-limit 2


2.2. Nuclear Medicine 100% Sub-limit 2 Sub-limit 2

3. General Practitioners and Specialists (In-Hospital Services)

- Additional Hospital Benefit Cover Included100% N$34 750 per Family

Overall Annual Limit Overall Annual Limit

4. Internal Appliances & Materials 100% of Cost As per NMC Protocol Overall Annual Limit

As per NMC ProtocolOverall Annual Limit

5. Dialysis (Subject to Case Management and MHC Guidelines) 100% of Cost Overall Annual Limit Overall Annual Limit

6. Oncology (All-inclusive In and Out-of-Hospital)(Subject to Case Management and MHC Guidelines) 100% Limited to N$350 000 per Beneficiary

Overall Annual LimitLimited to N$450 000 per Beneficiary


6.1. Consultations and Procedures 100% Sub-Limit 6 Sub-Limit 6

6.2. Hospitalisation 100% Sub-Limit 6 Sub-Limit 6

6.3. Radiation Oncology (Referral from medical specialist only) 100% Sub-Limit 6 Sub-Limit 6

6.4. Oncology Medication (Chemotherapy, Radiotherapy and Hormone Therapy) 100% Sub-Limit 6 Sub-Limit 6

7. Organ Transplant(Subject to Case Management and MHC Guidelines)

- Including medical expenses incurred by the donor if the recipient is a Fund member


8. Refractive Surgery No Benefit

Limited to N$5 950 per Beneficiary once offLimited to N$7 050 per Family

Overall Annual LimitGroups have cover from date of joining

Individuals have one year waiting period

9. Reconstructive Surgery (Medical necessity only)(Subject to prior approval and subject to strict MHC Guidelines)

No Benefit No Benefit

10. Private Nursing / Frail Care / Hospice (Subject to Case Management) 100% N$8 000 per Family

Overall Annual LimitN$10 500 per Family Overall Annual Limit

11. Psychiatric Treatment – Hospitalisation (Subject to prior approval) 100% Limited to N$31 500 per Family

Overall Annual LimitLimited to N$31 500 per Family



12. Alcoholism/Drug Addiction (Subject to prior approval and MHC Guidelines) 100% Sub-limit 11 Sub-limit 11

13. Specialised Dental Surgery – Hospitalisation Overall Annual Limit

13.1. Maxillo-Facial & Oral Surgery – Hospitalisation (Trauma/Non-Elective) 100% No Benefit Limited to N$57 000 per Family

Sub-limit 13

13.2. Maxillo-Facial & Oral Surgery – Hospitalisation (Other/Elective) 100% No Benefit

Limited to N$6 850 per Beneficiary Limited to N$10 900 per Family

Sub-limit 13

13.3. Dental Implant – Hospitalisation No Benefit No Benefit

13.4. Maxillo-Facial & Oral Surgery – Internal Prosthesis No Benefit Sub-limit 4

14. MaternityGroups have cover from date of joining.

Individuals have a 9-month waiting periodOverall Annual Limit

Groups have cover from date of joining. Individuals have a 9-month waiting period. Overall Annual Limit

14.1. Confinement – Full Procedure 100% Sub-limit 14 Sub-limit 14

14.2. Ante-natal Consultation - Additional Hospital Benefit Cover Excluded 100%

Limited to 12 consultations per Beneficiary(Pro-rated from date of joining)

Sub-limit 14


Sub-limit 14

14.3. Ante-natal Consultation / Post-natal Classes & Education

- Additional Hospital Benefit Cover Excluded100%

Limited to 6 sessions per Beneficiary per pregnancy(Pro-rated from date of joining)

Sub-limit 14


Sub-limit 14

14.4. Sonar Scans - Additional Hospital Benefit Cover Excluded 100% Limited to 3 scans per Beneficiary per Pregnancy

Sub-limit 14Limited to 3 scans per Beneficiary per Pregnancy

Sub-limit 14

14.5. Amniocentesis - Additional Hospital Benefit Cover Excluded 100% Sub-limit 14 Sub-limit 14

14.6. Midwifery Service - Additional Hospital Benefit Cover Excluded 100% Sub-limit 14 Sub-limit 14

15. Insertion of Intrauterine Device w/ Hormone (Mirena) (All-inclusive)(Subject to prior approval)

100% Limited to N$6 250 per BeneficiaryOverall Annual Limit

Limited to N$6 250 per BeneficiaryOverall Annual Limit


16. Stomaltherapy (All-inclusive In and Out-of-Hospital)*(Subject to prior approval)

100% Limited to N$17 000 per FamilyOverall Annual Limit

Limited to N$22 100 per FamilyOverall Annual Limit

17. Ambulance & Evacuation Services Overall Annual Limit Overall Annual Limit

17.1. Emergency Ambulance & Flights (Subject to Prior Approval) 100% Unlimited Benefit Unlimited Benefit

17.2. Ambulance/Inter-Hospital Transfer (Subject to prior approval) 100% N$2 390 per Family

Sub-limit 17N$4 250 per Family

Sub-limit 17

17.3. Other Transport(Subject to Prior Approval & Travelling Expenses Reimbursement Policy)

80% of Cost N$9 800 per FamilySub-limit 17

N$9 800 per FamilySub-limit 17

18. International Medical Travel Insurance - Medical cover when travelling to foreign

countries - For emergency cases only (not for elective

surgery or procedure)

100% of Cost N$10 000 000 per incident N$10 000 000 per incident

19. Specified Illness ConditionsLimited to N$41 000 per Family

(Sub-limits are pro-rated from date of joining)Overall Annual Limit

Limited to N$41 000 per Family (Sub-limits are pro-rated from date of joining)


19.1. HIV/AIDS(As per National Guidelines for Antiretroviral Therapy)

Limited to N$24 150 per Beneficiary Limited to N$24 150 per Beneficiary

19.1.1. MedicinePaid at Maximum Namibia Medicine Price List on Generics

100% Sub-limit 19.1 Sub-limit 19.1

19.1.2. First Full HIV Consultation/Assessment N$460 Once off benefitSub-limit 19.1

Once off benefitSub-limit 19.1

19.1.3. Consultation (after the first full HIV Consultation/Assessment) N$420 Limited to 6 consultations per Beneficiary

Sub-limit 19.1Limited to 6 consultations per Beneficiary

Sub-limit 19.1

19.1.4. HIV Counselling 100% Limited to N$1 250 per Beneficiary Sub-limit 19.1

Limited to N$1 250 per Beneficiary Sub-limit 19.1

19.1.5. Pathology Tests 100% Limited to N$5 450 per BeneficiarySub-limit 19.1

Limited to N$5 450 per BeneficiarySub-limit 19.1

*Pending approval by the Registrar of Medical aid Funds in Namibia/NAMFISA Namibia Medical Care | 2020 Benefit Guide 19

19.1.6. HIV Resistance Test (Subject to prior approval) 100% Sub-limit 18.1 Sub-limit 19.1

19.2. Prevention of Mother-to-Child Transmission (PMTCT) 100% Sub-limit 19.1

As per National GuidelinesSub-limit 19.1

As per National Guidelines

19.3. Post-Exposure Prophylaxis (PEP) 100% Sub-limit 19.1As per National Guidelines

Sub-limit 19.1As per National Guidelines

19.4. Pre-Exposure Prophylaxis (PrEP) 100% Sub-limit 19.1As per National Guidelines

Sub-limit 19.1As per National Guidelines

CATEGORY B: Day-To-Day Benefit Cover

Overall Sub-benefit limitN$17 850 per Beneficiary

N$24 150 per FamilyOVERALL ANNUAL LIMIT

Sub-limits are pro-rated from date of joining, except the Optical Benefit.OVERALL ANNUAL LIMIT

20. General Practitioners and Specialists N$6 000 per Family N$6 000 per BeneficiaryN$10 400 per Family

20.1. Consultations/Visits (Out-Of-Hospital, Including Casualties) 100% Sub-limit 20 Sub-limit 20

20.2. Procedures (Out-Of-Hospital Services, Including Casualties) 100% Sub-limit 20 Sub-limit 20

20.3. Materials and Disposable Items 100% Sub-limit 20 Sub-limit 20

20.4. Radiology and Pathology (Out-Of-Hospital, Including Radiography, Sonography, Medical Laboratory Technology and Chemical Biochemistry) (Referral from a Medical Practitioner)


20.5. MRI & CT Scans 100% Sub-limit 2 Sub-limit 2

Benefit Booster Applicable (Additional benefit once limit is exceeded) Refer to Sub-limit 28 Refer to Sub-limit 28

21. Medicine & Injections N$12 500 per Family N$14 100 per Family

21.1. Medicine (Acute & Chronic)Paid at Maximum Namibia Medicine Price List on Generics

100% N$6 250 per BeneficiarySub-limit 21

N$7 200 per BeneficiarySub-limit 21

21.2. Essential Vaccination/ImmunisationPaid at Maximum Namibia Medicine Price List on Generics



Benefit Booster Applicable(Additional benefit once limit is exceeded) Refer to Sub-limit 28 Refer to Sub-limit 28

21.3. Self-medication Paid at Maximum Namibia Medicine Price List on Generics

100%N$830 per Family

Limited to N$120 per claim per BeneficiarySub-limit 21

N$935 per FamilyLimited to N$145 per claim per Beneficiary

Sub-limit 21

22. Primary Health Care Services N$700 per Family N$300 per BeneficiaryN$1 000 per Family

22.1. Consultations & Procedures 100% Sub-limit 22 Sub-limit 22

22.2. Medicine & InjectionsPaid at Maximum Namibia Medicine Price List on Generics



23. Dentistry

23.1. Conservative & Specialised Dentistry (Including Dental Therapy) 100% N$4 350 per Family N$7 600 per Family


23.2. Dental Implants No Benefit No Benefit

23.3. Orthodontics 100% No Benefit Limited to N$8 800 per Beneficiary once-off

24. Optical N$3 530 per Family N$4 200 per Family

24.1. Eye Tests, Spectacles & Contact Lenses 100%N$1 300 per Beneficiary every 2 years

(Including frame) (2019/2020)Sub-limit 24

N$2 340 per Beneficiary every 2 years(Including frame) (2019/2020)

Sub-limit 24

24.2. Frame 100% of Cost N$520 per BeneficiarySub-limit 24.1

Limited to N$1 040 per BeneficiarySub-limit 24

25. Auxiliary Services N$2 280 per Family N$5 650 per Family

25.1. Consultation & Procedure 100% Sub-limit 25 Sub-limit 25

25.2. Medicine 100% Sub-limit 21.1 Sub-limit 21.1



26. External Appliances (Subject to MHC Guidelines) 80% of Cost N$ 2 600 per Family N$ 2 600 per Family

27. Wheelchair, Artificial Limbs, Artificial Eyes, Hearing Aid Apparatus, Devices for Diabetes Management

No Benefit No Benefit

28. Benefit BoosterApplicable if Medicine & Injections, Dentistry, GPs’ & Specialists, Primary Health Care & Auxiliary Services benefits are depleted

N$1 550 per Family N$ 2 900 per Family

28.1. Medicine & Injections (Acute & Chronic) - Excluding self-medication 70% Sub-limit 28 Sub-limit 28

28.2. Dentistry 70% Sub-limit 28 Sub-limit 28

28.3. General Practitioners & Specialists(Consultations/visits & procedures/services out-of-hospital, including casualties)


28.4. Primary Health Care 80% Sub-limit 28 Sub-limit 28

28.5. Auxiliary Services 70% Sub-limit 28 Sub-limit 28

29. Health SmartCard No additional costs. Each dependant receives his/her own SmartCard. Benefits can be verified at service providers 24/7. Next of kin can be contacted immediately.


Contribution Tables

Opal Individual Contributions Jade Individual Contributions

Age Band Main Adult Child Age Band Main Adult Child

0 25 1,601 997 444 0 25 1,673 1,112 496

26 30 1,771 1,121 444 26 30 1,863 1,258 496

31 35 1,930 1,259 444 31 35 2,052 1,407 496

36 40 2,162 1,423 452 36 40 2,313 1,606 496

41 45 2,369 1,561 452 41 45 2,539 1,786 496

46 50 2,538 1,706 452 46 50 2,743 1,942 527

51 55 2,761 1,882 452 51 55 3,001 2,142 527

56 60 2,945 2,019 452 56 60 3,209 2,302 527

61 65 3,134 2,159 452 61 65 3,429 2,474 527

66 3,326 2,315 452 66 3,643 2,642 527

Opal Group Contributions Jade Group Contributions

Income Band Main Adult Child Age Band Main Adult Child

0 3,870 1,399 906 258 0 25 1,482 968 428

3,871 5,120 1,611 1,028 296 26 30 1,641 1,081 428

5,121 7,830 1,725 1,067 318 31 35 1,754 1,182 428

7,831 11,500 1,774 1,144 327 36 40 1,916 1,307 428

11,501 12,930 1,985 1,271 366 41 45 2,112 1,463 428

12,931 14,660 2,198 1,398 406 46 50 2,249 1,567 437

51 55 2,427 1,715 437

56 60 2,600 1,844 437

61 65 2,756 1,968 437

66 2,769 1,981 437




Go through all that again

Stay strong


RUBY SAPPHIREN$1 040 000 per Beneficiary

N$1 560 000 per Family Unlimited Benefit

CATEGORY A: Hospitalisation Benefit % NAMAF Tariff

Pre-authorisation: 100% of tariff will be paid out.Without Pre-authorisation: No benefit will be paid out except in the

case of emergency hospital admissions and emergencies after-hours, weekends and public holidays.

Additional Hospital Benefit Cover: GP’s and Specialist’s in-hospital services are paid up to a maximum of 225% of NAMAF Tariff OVERALL LIMIT

COVER M M1 M2 M3 M4 M5+ M M1 M2 M3 M4 M5+

1. Hospitalisation Overall Annual Limit Overall Annual Limit



100%Limited to N$7 250 per Beneficiary and N$ 16 000 per

FamilySub-limit 1

Limited to N$10 500 per Beneficiary and N$23 000 per Family

Sub-limit 1

1.3. Accommodation Other than a Recognised Hospital/Medical Institution(Subject to prior approval & Accommodation Expenses Reimbursement Policy)

100% of CostLimited to N$600 per day per Family

(Maximum of 2 days) Sub-limit 1

Limited to N$600 per day per Family(Maximum 2 days)

Sub-limit 1


1.5. Intensive and High Care (Maximum 3 days, then motivation) 100% Sub-limit 1 Sub-limit 1



1.7. Radiology & Pathology (In-Hospital) - Additional hospital benefit cover excluded 100% Sub-limit 1 Sub-limit 1


2. Specialised Radiology Procedures (In & Out Of Hospital)Additional hospital benefit cover excluded

- Referral from a medical specialist only (referral from GP acceptable in places where there is no medical specialist).(Subject to prior approval)


2.1 MRI & CT Scans 100% Limited to N$18 000 per FamilySub-limit 2

Limited to N$31 500 per FamilySub-limit 2

2.2 Nuclear Medicine 100% Sub-limit 2 Sub-limit 2

3. General Practitioners and Specialists (In-Hospital Services) - Additional hospital benefit cover included


4. Internal Appliances & Materials 100% of Cost As per NMC ProtocolOverall Annual Limit


5. Dialysis (Subject to Case Management and MHC Guidelines) 100% Overall Limit Overall Annual Limit

6. Oncology (All-inclusive In and Out of Hospital) (Subject to Case Management and MHC Guidelines)



6.1. Consultation and Procedure 100% Sub-limit 6 Sub-Limit 6

6.2. Hospitalisation 100% Sub-limit 6 Sub-Limit 6

6.3. Radiation Oncology(Referral from medical specialist only) 100% Sub-limit 6 Sub-Limit 6

6.4. Oncology Medication (Chemotherapy, Radiotherapy and Hormone Therapy) 100% Sub-limit 6 Sub-Limit 6

7. Organ Transplant (Subject to Case Management and MHC Guidelines) - Including medical expenses incurred by the donor

if the recipient is a Fund member


8. Refractive Surgery – All-inclusive (Subject to prior approval and MHC Guidelines) 100%



Individuals have one year waiting period



Individuals have a one-year waiting period


9. Reconstructive Surgery (Medical necessity only) (Subject to prior approval and subject to strict MHC Guidelines)


9.1. Consultation and Procedure 100% Limited to N$6 500 per FamilySub-limit 9


9.2. Hospitalisation 100% Sub-limit 9 Sub-limit 9

10. Private Nursing (Subject to Case Management) 100% Limited to N$21 000 per Family



11. Frail Care / Hospice (Subject to Case Management) 100% Sub-limit 10 Sub-limit 10

12. Psychiatric Treatment - Hospitalisation (Subject to prior approval) 100% Limited to N$31 500 per Family



13. Alcoholism/Drug Addiction (Subject to prior approval and MHC Guidelines) 100% Sub-limit 12 Sub-limit 12

14. Specialised Dental Surgery – Hospitalisation (Subject to pre-authorisation) Overall Annual Limit Overall Annual Limit

14.1 Maxillo-Facial & Oral Surgery – Hospitalisation (Trauma/Non-elective) 100% Limited to N$92 500 per Family

Sub-limit 14Limited to N$132 000 per Family

Sub-limit 14

14.2 Maxillo-Facial & Oral Surgery – Hospitalisation (Other/Elective) 100%

Limited to N$9 600 per BeneficiaryLimited to N$14 000 per Family

Sub-limit 14


Sub-limit 14

14.3 Dental Implant – Hospitalisation 100% Sub-limit 14.2 Sub-limit 14.2

14.4 Maxillo-Facial & Oral Surgery – Internal Prosthesis 100% of Cost Sub-limit 4 Sub-limit 4


15. MaternityGroups have cover from date of joining


Groups have cover from date of joining Individuals have a 9-month waiting period


15.1. Confinement – Full Procedure 100% Overall Limit Sub-limit 15

15.2. Ante-natal Consultation – Additional Hospital Benefit Cover Excluded 100%

Limited to 12 consultations per Beneficiary (Pro-rated from date of joining)

Sub-limit 15

Limited to 12 consultations per Beneficiary (Pro-rated from date of joining)

Sub-limit 15

15.3. Ante-natal Consultation / Post-natal Classes & Education

- Additional Hospital Benefit Cover Excluded100%


Sub-limit 15


Sub-limit 15

15.4. Sonar Scans - Additional Hospital Benefit Cover Excluded 100% Limited to 3 scans per Beneficiary per Pregnancy


Sub-limit 15






17. Stomaltherapy (All-inclusive) (Subject to prior approval) 100% Limited to N$28 750 per Family




18.1. Emergency Ambulance & Flights (Territory: SADC Countries)(Subject to prior approval)

100% Unlimited Benefit Unlimited Benefit

18.2. Ambulance/Inter-Hospital Transfer (Subject to prior approval) 100% Sub-limit 18 Sub-limit 18

18.3. Other Transport (Subject to prior approval & Travelling Expenses Reimbursement Policy)

80% of Cost N$9 800 per Family Sub-limit 18

N$9 800 per Family Sub-limit 18

19. International Medical Travel Insurance - Medical cover when travelling to foreign countries - For emergency cases only (not for elective surgery

or procedure)

100% of Cost N$10 000 000 per incident N$10 000 000 per incident


CATEGORY B: DAY-TO-DAY BENEFIT COVERSub-limits are pro-rated from date of joining, except the Optical Benefit.

OVERALL LIMIT

M M1 M2 M3 M4 M5+ M M1 M2 M3 M4 M5+

20. General Practitioners and Specialists N$8 250 N$10 750 N$11 250 N$11 500 N$11 750 N$12 000 N$13 750 N$17 500 N$19 500 N$19 750 N$20 000 N$20 250

20.1. Consultations/Visits (out-of-hospital, including casualties) 100% Sub-limit 20 Sub-limit 20

20.2. Procedures/Services (out-of-hospital, including casualties) 100% Sub-limit 20 Sub-limit 20

20.3. Materials and Disposable Items 100% Sub-limit 20 Sub-Limit 20

20.4. Radiology and Pathology (Out-Of-Hospital, Including Radiography, Sonography, Medical Laboratory Technology and Chemical Biochemistry) (Referral from a Medical Practitioner)

100% Sub-limit 20 Sub-Limit 20

20.5. MRI & CT Scans 100% Sub-limit 2 Sub-limit 2

Benefit Booster applicable (Additional benefit once limit is exceeded) Refer to Sub-limit 33 Refer to Sub-limit 33

21. Dentistry

21.1. Conservative & Specialised Dentistry (Including Dental Therapy) 100%

N$10 100 N$11 750 N$13 000 N$13 500 N$13 750 N$14 000 N$15 250 N$18 250 N$20 000 N$20 500 N$21 000 N$21 500


21.2. Dental Implants – Consultation, Procedure and Cost of Dental Implant Components (Subject to Pre-Authorisation)

The available benefits are for either in-hospital or in-practice


21.2.1. In-Hospital 100%Limited to N$9 750 per Beneficiary

Limited to N$17 750 per FamilyLimited to N$3 650 per dental implant component

Limited to N$14 000 per BeneficiaryN$23 000 per Family

Limited to N$3 650 per dental implant component

21.2.2. In-Practice 150%Limited to N$18 250 per Beneficiary

Limited to N$28 500 per FamilyLimited to N$3 650 per dental implant component


Limited to N$3 650 per dental implant component


21.3. Orthodontics (Subject to prior approval and MHC Guidelines) 100% Limited to N$12 750 per Beneficiary once off Limited to N$22 250 per Beneficiary once off


21.4. Maxillo-Facial and Oral Surgery (Elective and Non-Elective)

- Consultation & Procedure (Subject to Pre-Authorisation)



21.4.1. In-Hospital 100%N$5 500 N$6 750 N$7 250 N$7 750 N$8 250 N$8 750 N$6 000 N$7 000 N$7 500 N$8 000 N$8 500 N$9 000


21.4.2. In-Practice 150%N$8 250 N$10 250 N$11 000 N$11 750 N$12 500 N$12 750 N$9 250 N$10 750 N$11 500 N$12 250 N$13 000 N$13 500

Limited to N8 250 per Beneficiary Limited to N$9 250 per Beneficiary

22. Medicine & Injections N$14 090 N$15 490 N$16 140 N$16 790 N$17 440 N$18 040 N$29 370 N$45 670 N$49 620 N$50 520 N$51 170 N$51 820

22.1. Acute – Paid at Maximum Namibia Medicine Price List on Generics 80%

N$5 200 N$5 450 N$5 700 N$5 950 N$6 200 N$6 450 N$8 050 N$12 200 N$15 000 N$15 500 N$15 750 N$16 000



22.2. Chronic – Paid at Maximum Namibia Medicine Price List on Generics N$7 800 N$8 850 N$9 100 N$9 350 N$9 600 N$9 850 N$19 500 N$31 500 N$32 500 N$32 750 N$33 000 N$33 250

22.2.1. Members aged 65 and below 80% No Limit per BeneficiarySub-limit 22

No limit per BeneficiarySub-limit 2222.2.2. Members aged 66 and above 100%

22.3. Essential Vaccination/Immunisation (As per WHO Guidelines)Paid at Maximum Namibia Medicine Price List on Generics



22.4. Self-medication Paid at Maximum Namibia Medicine Price List on Generics

100%

N$1 090 N$1 190 N$1 340 N$1 490 N$1 640 N$1 740 N$1 820 N$1 970 N$2 120 N$2 270 N$2 420 N$2 570

Limited to N$176 per claim per Beneficiary per daySub-limit 22

Limited to N$217 per claim per Beneficiary per daySub-limit 22

23. Optical BenefitsN$3 350 N$4 750 N$5 000 N$5 250 N$5 500 N$5 750 N$4 900 N$8 700 N$9 450 N$9 950 N$10 200 N$10 450

Limited to N$3 350 per Beneficiary every 2 years (Including frame) (2019-2020)

Limited to N$4 900 per Beneficiary every 2 years (Including frame) (2019-2020)

23.1. Optical Tests 100% Sub-limit 23 Sub-limit 23

23.2. Spectacles and Lenses 100% Sub-limit 23 Sub-limit 23

23.3. Frame 100% of Cost Limited to N$1 140 per BeneficiarySub-limit 23



23.4. Readers Spectacles 100% of Cost Limited to N$105 per BeneficiarySub-limit 23

Limited to N$105 per FamilySub-limit 23

24. Primary Health Care ServicesN$400 N$600 N$800 N$1 000 N$1 200 N$1400 N$500 N$750 N$1 000 N$1 250 N$1 500 N$1 750

Limited to N$400 per Beneficiary Limited to N$500 per Beneficiary

24.1. Consultations and Procedures 100% Sub-limit 24 Sub-limit 24

24.2. Medicine & InjectionsPaid at Maximum Namibia Medicine Price List on Generics

100% Sub-limit 22.1 Sub-Limit 22.1


25. Auxiliary ServicesN$11 400 N$12 400 N$12 650 N$12 900 N$13 150 N$13 400 N$14 750 N$23 500 N$25 500 N$26 750 N$27 250 N$27 750


25.1. Art Therapy 100% Sub-limit 25 Sub-limit 25

25.2. Audiology/Speech Therapy 100% Sub-limit 25 Sub-limit 25

25.3. Biokinetics 100% Limited to N$3 890 per BeneficiarySub-limit 25


25.4. Chiropractor25.4.1. Consultation & Procedure25.4.2. Medicine

100%80%

Sub-limit 25Sub-limit 22.1


25.5. Clinical Psychology/Psychological Counsellor 100% Limited to N$3 890 per BeneficiarySub-limit 25


25.6. Clinical Technology 100% Sub-limit 25 Sub-limit 25

25.7. Dietician 100% Sub-limit 25 Sub-limit 25

25.8. Hearing Aid Acoustician 100% Sub-limit 25 Sub-limit 25

25.9. Homeopathy/Naturopathy/Phytotherapy25.9.1. Consultation & Procedure25.9.2. Medicine

100%80%



25.10. Occupational Therapy 100% Sub-limit 25 Sub-limit 25

25.11. Orthotist/Prosthetist 100% Sub-limit 25 Sub-limit 25


25.12. Physiotherapy 100% Limited to N$3 890 per BeneficiarySub-limit 25


25.13. Podiatry/Chiropody 100% Sub-limit 25 Sub-limit 25

25.14. Social Worker 100% Limited to N$3 890 per BeneficiarySub-limit 25

Limited to N$7 270 per Beneficiary Sub-limit 25


26. Wheelchair (Subject to prior approval)

- Inclusive of repair & maintenance100% of Cost Limited to N$8 850 per Beneficiary every 4 years

(2020-2023)Limited to N$17 750 per Beneficiary every 4 years

(2020 – 2023)

27. Artificial Limbs (Subject to prior approval) 100% of Cost Limited to N$17 750 per Beneficiary every 2 years


(2020 – 2021)

28. Artificial Eyes (Subject to prior approval) 100% of Cost Limited to N$5 750 per Beneficiary every 4 years


(2020 – 2023)

29. Hearing Aid Apparatus (Subject to prior approval)

- Inclusive of repair & maintenance100% of Cost Limited to N$25 000 per Family every 2 years

(2020-2021)Limited to N$31 250 per Family every 2 years

(2020 – 2021)

30. Appliances (External) (Subject to MHC Guidelines) 80% of Cost Limited to N$4 400 per Family Limited to N$4 950 per Family

31. Medical Devices for Diabetes Management (Subject to prior approval and MHC Guidelines)

31.1. Insulin Pumps / Glucose Monitoring System / Glucose Reader 80% of Cost Limited to N$35 000 per Beneficiary every 4 years

(2019– 2022)Limited to N$40 000 per Beneficiary every 4 years

(2019 – 2022)

31.2. Diabetes Related Consumables 80% of Cost Limited to N$2 000 per Beneficiary Limited to N$2 500 Beneficiary

32. Specified Illness Conditions N$30 000 N$43 000 N$43 000 N$43 000 N$43 000 N$43 000 N$34 750 N$69 500 N$69 500 N$69 500 N$69 500 N$69 500

32.1. HIV/AIDS (As per National Guidelines for Antiretroviral Therapy) Limited to N$30 000 per Beneficiary Limited to N$34 750 per Beneficiary

32.1.1. MedicinePaid at Maximum Namibia Medicine Price List on Generics


32.1.2. First Full HIV Consultation/Assessment N$460 Once off benefit

Sub-limit 32.1Once off benefitSub-limit 32.1


32.1.3. Consultation (after the first full HIV Consultation/Assessment) N$420 Limited to 6 consultations per Beneficiary

Sub-limit 32.1Limited to 6 Consultations per Beneficiary

Sub-limit 32.1

32.1.4. HIV Counselling 100% Limited to N$1 250 per BeneficiarySub-limit 32.1


32.1.5. Pathology Tests 100% Limited to N$5 720 per Beneficiary Sub-limit 32.1


32.1.6. HIV Resistance Test (Subject to prior approval) 100% Sub-limit 32.1 Sub-limit 32.1

32.2. Prevention of Mother-to-Child Transmission (PMTCT) 100% Sub-limit 32.1

As per National GuidelinesSub-limit 32.1

As per National Guidelines

32.3. Post-Exposure Prophylaxis (PEP) 100% Sub-limit 32.1As per National Guidelines

Sub-limit 32.1 As per National Guidelines

32.4. Pre-Exposure Prophylaxis (PrEP) 100% Sub-limit 32.1As per National Guidelines

Sub-limit 32.1 As per National Guidelines

33. Benefit BoosterApplicable if Medicine & Injections, Dentistry, GPs & Specialists, Primary Health Care and Auxiliary Services Benefits are depleted



33.1. Medicine & Injections (Acute & Chronic) – Excluding self-medication 70% Sub-limit 33 Sub-limit 33

33.2. Dentistry & Dental Implant (Excluding Orthodontics) 70% Sub-limit 33 Sub-limit 33

33.3. General Practitioners & Specialists (Consultations/Visits & Procedures/Services out-of-hospital, including casualties)(Consultations/visits & procedures/services out-of-hospital, including casualties)


33.4. Primary Health Care 80% Sub-limit 33 Sub-limit 33

33.5. Auxiliary Services 70% Sub-limit 33 Sub-limit 33

34. Health SmartCard No Additional Costs. Each Dependant will receive his/her own smartcard. Benefits can be verified at Service Providers 24/7. Next of Kin can be contacted immediately.


Contribution Tables

Ruby Individual Contributions Sapphire Individual Contributions

Age Band M0 M1 M2 M3 M4 M5+ Age Band Main Adult Child

0 25 2,222 3,741 4,428 5,110 5,799 6,461 0 25 2,808 2,249 1,000

26 30 2,477 4,211 4,892 5,570 6,254 6,930 26 30 3,183 2,543 1,000

31 35 2,726 4,646 5,332 6,016 6,696 7,378 31 35 3,555 2,823 1,000

36 40 3,074 5,262 5,948 6,643 7,341 8,036 36 40 4,047 3,211 1,000

41 45 3,374 5,801 6,499 7,201 7,921 8,618 41 45 4,501 3,554 1,000

46 50 3,645 6,288 6,977 7,675 8,371 9,060 46 50 4,903 3,858 1,015

51 55 3,988 6,875 7,578 8,281 8,978 9,677 51 55 5,399 4,230 1,015

56 60 4,264 7,374 8,072 8,767 9,457 10,159 56 60 5,814 4,551 1,015

61 65 4,557 7,892 8,591 9,271 9,960 10,642 61 65 6,246 4,884 1,015

66 4,842 8,416 9,115 9,785 10,458 11,151 66 6,692 5,208 1,015

Ruby Group Contributions Sapphire Group Contributions

Age Band M0 M1 M2 M3 M4 M5+ Age Band Main Adult Child

0 25 1,969 3,256 3,825 4,405 4,980 5,553 0 25 2,501 1,906 830

26 30 2,181 3,618 4,188 4,757 5,336 5,898 26 30 2,748 2,101 830

31 35 2,331 3,902 4,463 5,013 5,576 6,127 31 35 2,960 2,267 830

36 40 2,546 4,283 4,836 5,381 5,942 6,491 36 40 3,333 2,568 830

41 45 2,807 4,751 5,314 5,880 6,437 7,002 41 45 3,728 2,858 830

46 50 2,989 5,070 5,617 6,174 6,722 7,270 46 50 4,010 3,089 840

51 55 3,225 5,505 6,043 6,615 7,173 7,711 51 55 4,374 3,366 840

56 60 3,455 5,905 6,454 7,000 7,559 8,105 56 60 4,833 3,718 840

61 65 3,663 6,277 6,828 7,360 7,904 8,443 61 65 5,129 3,933 84066 3,680 6,311 6,861 7,391 7,941 8,483 66 5,135 3,941 840


A: Keep on running B: Say hi




EMERALD AMBERN$1 040 000 per Beneficiary

N$1 560 000 per Family Unlimited

CATEGORY A: Benefits For Major Medical Expenses

% NAMAF Tariff


case of emergency hospital admissions and emergencies after-hours, weekends and public holidays.OVERALL LIMIT

Additional Hospital Benefit Cover: GP’s and Specialist’s In-Hospital services are paid up to a maximum of 225% of NAMAF Tariff.OVERALL LIMIT






FamilySub-limit 1

Limited to N$10 500 per Beneficiary and 23 000 per Family

Sub-limit 1

1.3. Accommodation Other than a Recognised Hospital/Medical Institution(Subject to prior approval & accommodation expenses Reimbursement policy)

100% of Cost


Sub-limit 1


Sub-limit 1


1.5. Intensive and High Care(Maximum 3 days, then motivation) 100% Sub-limit 1 Sub-limit 1







2.1. MRI & CT Scans 100% Limited to N$18 000 per FamilySub-limit 2





- Additional Hospital Benefit Cover Included100% Overall Annual Limit Overall Annual Limit

4. Medical and Surgical Appliances (External) No Benefit No Benefit

5. Internal Appliances & Materials 100% of Cost



6. Dialysis (Subject to Case Management and MHC Guidelines) 100% Overall Annual Limit Overall Annual Limit

7. Oncology – Active Therapy (All-inclusive In and Out of Hospital)(Subject to Case Management and MHC Guidelines)

Limited to N$600 000 per Beneficiary Overall Annual Limit


7.1. Consultations and Procedures 100% Sub-Limit 7 Sub-Limit 7

7.2. Hospitalisation 100% Sub-Limit 7 Sub-Limit 7

7.3. Radiation Oncology (Referral from a medical specialist only) 100% Sub-Limit 7 Sub-Limit 7

7.4. Oncology Medication (Chemotherapy, Radiotherapy and Hormone Therapy) 100% Sub-Limit 7 Sub-Limit 7

8. Organ Transplant (Subject to Case Management and MHC Guidelines)



9. Refractive Surgery – All-inclusive(Subject to prior approval and MHC Guidelines) 100%

Limited to N$6 000 per Beneficiary once off Limited to N$7 250 per Family

Groups have cover from date of joiningIndividuals have one year waiting period





10. Reconstructive Surgery (Medical Necessity Only)(Subject to prior approval and subject to strict MHC Guidelines)


10.1. Consultation and Procedures 100% Limited to N$6 500 per FamilySub-limit 10







12. Frail Care / Hospice(Subject to Case Management) 100% Sub-limit 11 Sub-limit 11




14. Alcoholism / Drug Addiction (Subject to prior approval and MHC Guidelines) 100% Sub-limit 13 Sub-limit 13

15. Medication and Injections - Chronic No Benefit No Benefit

16. Specialised Dental Surgery - Additional Hospital Benefit Cover Excluded

(Subject to Pre-Authorisation)Overall Annual Limit Overall Annual Limit

16.1. Maxillo-Facial & Oral Surgery - All-inclusive (Hospitalisation, Consultation &

Procedure) (Trauma/Non-Elective)

100% Limited to N$92 500 per FamilySub-limit 16



Procedure) (Other/Elective)

100%Limited to N$9 600 per Beneficiary



Sub-limit 16

16.3. Dental Implant – Hospitalisation 100% Sub-limit 16.2 Sub-limit 16.2

16.4. Maxillo-Facial & Oral Surgery – Internal Prosthesis (Excluding dental implant component)









Sub-limit 17


Sub-limit 17

17.3. Ante / Post-natal Classes & Education - Additional Hospital Benefit Cover Excluded 100%


Sub-limit 17


Sub-limit 17

17.4. Sonar Scans (excluding 3D) - Additional Hospital Benefit Cover Excluded 100% Limited to 3 scans per Beneficiary per Pregnancy


Sub-limit 17







19. Stomaltherapy (All-inclusive)(Subject to prior approval) 100% Limited to N$28 750 per Family




20.1. Emergency Ambulance & Flights (Territory: SADC Countries)(Subject to Prior Approval)




80% of Cost






100% of Cost

N$10 000 000 per incident N$10 000 000 per incident

22. Health SmartCard No Additional Costs. Each Dependant will receive his/her own smartcard. Benefits can be verified at Service Providers 24/7. In case of Emergency, Member and Dependants can be identified without Health Smartcard. Next of Kin can be contacted immediately.


Contribution Tables

Emerald Individual Contributions Amber Individual Contributions


0 25 924 585 231 0 25 1,234 777 277

26 30 1,028 658 231 26 30 1,372 878 277

31 35 1,135 734 231 31 35 1,514 974 277

36 40 1,283 828 236 36 40 1,709 1,102 284

41 45 1,406 920 236 41 45 1,875 1,227 284

46 50 1,519 1,002 236 46 50 2,026 1,336 284

51 55 1,659 1,105 236 51 55 2,212 1,471 284

56 60 1,778 1,188 236 56 60 2,366 1,588 284

61 65 1,894 1,275 236 61 65 2,524 1,702 284

66 2,020 1,358 236 66 2,691 1,813 284

Emerald Group Contributions Amber Group Contributions


0 25 933 591 218 0 25 1,246 784 264

26 30 1,038 665 218 26 30 1,385 886 264

31 35 1,103 681 218 31 35 1,472 905 264

36 40 1,189 726 223 36 40 1,583 968 271

41 45 1,272 798 223 41 45 1,695 1,065 271

46 50 1,380 876 223 46 50 1,844 1,168 271

51 55 1,426 916 223 51 55 1,903 1,222 271

56 60 1,509 982 223 56 60 2,012 1,310 271

61 65 1,636 1,067 223 61 65 2,181 1,420 271

66 1,675 1,094 223 66 2,232 1,460 271



EMERALD PLUS AMBER PLUSN$1 040 000 per Beneficiary

N$1 560 000 per Family Unlimited Benefit

CATEGORY A: Benefits For Major Medical Expenses

% NAMAF Tariff


case of emergency hospital admissions and emergencies after-hours, weekends and public holidays.OVERALL LIMIT

Additional Hospital Benefit Cover: GP’s and Specialist’s In-Hospital services are paid up to a maximum of 225% of NAMAF Tariff.OVERALL LIMIT






FamilySub-limit 1

Limited to N$10 500 per Beneficiary and 23 000 per Family

Sub-limit 1

1.3. Accommodation Other than a Recognised Hospital/Medical Institution(Subject to prior approval & accommodation expenses Reimbursement policy)

100% of costLimited to N$600 per day per Family

(Maximum 2 days)Sub-limit 1


Sub-limit 1


1.5. Intensive and High Care(Maximum 3 days, then motivation) 100% Sub-limit 1 Sub-limit 1








2.1. MRI & CT Scans 100% Limited to N$18 000 per FamilySub-limit 2




- Additional Hospital Benefit Cover Included100% Overall Annual Limit Overall Annual Limit

4. Medical and Surgical Appliances (External) Refer to Category B: Day to Day Back Up Benefit Refer to Category B: Day to Day Back Up Benefit

5. Internal Appliances & Materials 100% of cost As per NMC ProtocolOverall Annual Limit


6. Dialysis (Subject to Case Management and MHC Guidelines) 100% Overall Annual Limit Overall Annual Limit

7. Oncology (All-inclusive In and Out of Hospital)(Subject to Case Management and MHC Guidelines)



7.1. Consultations and Procedures

100%

Sub-Limit 7 Sub-Limit 7

7.2. Hospitalisation Sub-Limit 7 Sub-Limit 7

7.3. Radiation Oncology (Referral from a medical specialist only) Sub-Limit 7 Sub-Limit 7

7.4. Oncology Medication (Chemotherapy, Radiotherapy and Hormone Therapy) Sub-Limit 7 Sub-Limit 7

8. Organ Transplant (Subject to Case Management and MHC Guidelines)



9. Refractive Surgery – All-inclusive(Subject to prior approval and MHC Guidelines) 100%

Limited to N$6 000 per Beneficiary once off Limited to N$7 250 per Family







10. Reconstructive Surgery (Medical Necessity Only)(Subject to prior approval and subject to strict MHC Guidelines)


10.1. Consultation and Procedures 100% Limited to N$6 500 per FamilySub-limit 10






12. Frail Care / Hospice (Subject to Case Management) 100% Sub-limit 11 Sub-limit 11




14. Alcoholism / Drug Addiction (Subject to prior approval and MHC Guidelines) 100% Sub-limit 13 Sub-limit 13

15. Medication and Injections - Chronic Refer to Category B: Day to Day Back Up Benefit Refer to Category B: Day to Day Back Up Benefit

16. Specialised Dental Surgery - Additional Hospital Benefit Cover Excluded

(Subject to Pre-Authorisation)Overall Annual Limit Overall Annual Limit


Procedure) (Trauma/Non-Elective)

100% Limited to N$92 500 per FamilySub-limit 16



Procedure) (Other/Elective)




Sub-limit 16

16.3. Dental Implant – Hospitalisation 100% Sub-limit 16.2 Sub-limit 16.2

16.4. Maxillo-Facial & Oral Surgery – Internal Prosthesis (Excluding dental implant component)










Sub-limit 17


Sub-limit 17

17.3. Ante / Post-natal Classes & Education - Additional Hospital Benefit Cover Excluded 100%


Sub-limit 17


Sub-limit 17

17.4. Sonar Scans (excluding 3D) - Additional Hospital Benefit Cover Excluded 100% Limited to 3 scans per Beneficiary per Pregnancy


Sub-limit 17





Overall Annual LimitLimited to N$6 250 per Beneficiary


19. Stomaltherapy (All-inclusive)(Subject to prior approval) 100% Limited to N$28 750 per Family




20.1. Emergency Ambulance & Flights (Territory: SADC Countries)(Subject to Prior Approval)




80% N$9 800 per Family Sub-limit 20





100% of cost N$10 000 000 per incident N$10 000 000 per incident


CATEGORY B:Day-To-Day Backup Benefit

100% Tariff

Limited to:N$6 000 Member only

N$10 200 Member + AdultN$7 200 Member + Child

N$11 400 Member + Adult+ ChildAdditional N$ 1 200 benefit for each additional Child

OVERALL ANNUAL LIMITBenefits are pro-rated from Date of Joining

Ex Gratia not Applicable

Limited to:N$9 000 member only

N$15 000 Member + AdultN$11 400 Member + Child

N$17 400 Member + Adult+ ChildAdditional N$ 2 400 for each additional Child

OVERALL ANNUAL LIMITBenefits are pro-rated from Date of Joining

Ex Gratia not Applicable

Rules on Day-to-Day Back-up Benefit:

Ninety-five percent (95%) of unused Day-to-Day Back-Up benefit will be carried over to the following financial year. If a member uses less than the full benefit, then 95% of the unused benefit will be accumulated over to the next year.

The unused benefit will be forfeited and cannot be paid back to the member upon principal member’s resignation from the fund, or the principal member’s death or the principal member’s migration to Traditional option.

The total amount is available for the family and is not limited per beneficiary.

22. General Practitioners & Specialists (out-of-hospital including casualties)

22.1. Consultations/Visits22.2. Procedures/Services (out-of-hospital,

including casualties)22.3. Materials and Disposable Items22.4. Radiology & Pathology Out-of-hospital,

including Radiography, Sonography, Medical Laboratory Technology and Chemical Biochemistry) (Referral from a Medical Practitioner)

100% Paid from Day to Day Back-up Benefit Paid from Day to Day Back-up Benefit

23. Dentistry23.1. Conservative & Specialised Dentistry

(including Dental Therapy)23.2. Dental Implants (In-Hospital & In-Practice)

(Subject to Pre-authorisation)23.3. Orthodontics (Subject to prior approval and

MHC Guidelines)23.4. Maxillo-Facial and Oral Surgery (In-Hospital &

In-Practice)



24. Medicine & Injections24.1. Acute Medicine & Injections24.2. Chronic Medicine & Injections24.3. Essential Vaccination / Immunisation

(As per WHO Guidelines)24.4. Self Medication

100%Paid from Day to Day Back-up Benefit

Paid at Maximum Namibia Medicine Price List on generics

Paid from Day to Day Back-up Benefit Paid at Maximum Namibia Medicine Price List on

generics

25. Primary Health Care Services25.1. Consultations and Procedures25.2. Medicine & Injections

100%Paid from Day to Day Back-up Benefit


Paid from Day to Day Back-up Benefit Paid at Maximum Namibia Medicine Price List on

generics

26. Auxiliary Services (Supplementary Services)26.1. Art Therapy26.2. Audiology/Speech Therapy26.3. Biokineticist26.4. Chiropractor

26.4.1. Consultation & Procedure26.4.2. Medicine

26.5. Clinical Psychology / Psychological Counsellor26.6. Clinical Technology26.7. Dietician26.8. Hearing Aid Acoustician26.9. Homeopathy/Naturopathy/ Phytotherapy

26.9.1. Consultation & Procedure26.9.2. Medicine

26.10. Occupational Therapy26.11. Orthotist/Prosthetist26.12. Physiotherapy26.13. Podiatry/Chiropody26.14. Social Worker


27. Medical and Surgical Appliances (External)(Subject to MHC Guidelines) 100% of cost Paid from Day to Day Back-up Benefit Paid from Day to Day Back-up Benefit

28. Optical28.1. Optical Tests28.2. Spectacles & lenses28.3. Frame28.4. Reader Spectacles



29. Specified Illness Conditions29.1. HIV/AIDS (As per National Guidelines for

Antiretroviral Therapy)29.1.1. Medicine29.1.2. First Full HIV Consultation /

Assessment29.1.3. Consultation (after the first full HIV

consuitation / assessment)29.1.4. HIV Counselling29.1.5. Pathology Tests29.1.6. HIV Resistance Test (Subject to prior

approval)29.2. Prevention of Mother-to-Child Transmission

(PMTCT)29.3. Post-Exposure Prophylaxis (PEP)29.4. Pre-Exposure Prophylaxis (PrEP)

100%Paid from Day to Day Back Up Benefit


Paid from Day to Day Back Up BenefitPaid at Maximum Namibia Medicine Price List on

generics

30. Health SmartCardNo Additional Costs. Each Dependant will receive his/her own smartcard. Benefits can be verified at Service

Providers 24/7. Next of Kin can be contacted immediately.


Contribution Tables

Emerald Plus Individual Contributions Amber Plus Individual Contributions


0 25 1,424 935 331 0 25 1,984 1,277 477

26 30 1,528 1,008 331 26 30 2,122 1,378 477

31 35 1,635 1,084 331 31 35 2,264 1,474 477

36 40 1,783 1,178 336 36 40 2,459 1,602 484

41 45 1,906 1,270 336 41 45 2,625 1,727 484

46 50 2,019 1,352 336 46 50 2,776 1,836 484

51 55 2,159 1,455 336 51 55 2,962 1,971 484

56 60 2,278 1,538 336 56 60 3,116 2,088 484

61 65 2,394 1,625 336 61 65 3,274 2,202 484

66 2,520 1,708 336 66 3,441 2,313 484

Emerald Plus Group Contributions Amber Plus Group Contributions


0 25 1,433 941 318 0 25 1,996 1,284 464

26 30 1,538 1,015 318 26 30 2,135 1,386 464

31 35 1,603 1,031 318 31 35 2,222 1,405 464

36 40 1,689 1,076 323 36 40 2,333 1,468 471

41 45 1,772 1,148 323 41 45 2,445 1,565 471

46 50 1,880 1,226 323 46 50 2,594 1,668 471

51 55 1,926 1,266 323 51 55 2,653 1,722 471

56 60 2,009 1,332 323 56 60 2,762 1,810 471

61 65 2,136 1,417 323 61 65 2,931 1,920 471

66 2,175 1,444 323 66 2,982 1,960 471


Nam

ibia Medical Care

PO Box 24792

WIN

DH

OEK, N

AM

IBIA

APPLICATIO

N TO

EXERCISE OPTIO

N CH

AN

GE 2020

Surnam

e

Initials

Mem

bership No.

E-m

ail

Cell

CU

RR

ENT O

PTION

: 2019Indicate w

ith an X:

TO

PAZ

TOPA

Z PLUS

OPA

LJA

DE

RU

BY

SAPPH

IRE

DIA

MO

ND

EM

ERA

LD

AM

BER

NEW

OPTIO

N: 2020

Indicate with an X

:

1. S

hould you be registered as an individual mem

ber, this application form m

ust reach our offices on or before 15 January 2020 (either by

post, fax or e-mail).

2. M

embers w

ho are registered under a group scheme m

ust please forward the option change form

to their Hum

an Resources D

epartment,

w

here changes must be recorded and then forw

arded to NM

C.

3. K

indly take note, should NM

C not receive your application for option change on or before 15 January 2020, it w

ill be assumed that you

rem

ain on the same option as 2019.

4. P

LEA

SE

CO

MP

LETE

THE

RE

VE

RS

E S

IDE

OF TH

IS FO

RM

AS

WE

LL.5.

Would you prefer to receive your rem

ittance statement via e-m

ail? Yes

No

NB

: Please ensure that your e-m

ail address is correct on the reverse side of this form.

PLE

AS

E N

OTE

: You have until 15/01/2020 to make your decision. The change becom

es effective on 1 January 2020.

Signature of M

ember _____________________________

Date __________________________

Approval of C

ompany _________________________________

(Signature of C

ompany O

fficial)

Tel. (061) 287 6040Fax (061) 287 6049

E-mail: FinReception@

methealth.com

.na

TO

PAZ

TOPA

Z PLUS

OPA

LJA

DE

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UB

Y SA

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Documents

BENEFIT GUIDE 2020 - My · New Generation Options – New Generation Options – the new generation options, Emerald and Amber, cater for comprehensive hospital cover. New options,