Emerald Plus

Key Benefits

Hospital: Major Medical Expenses

Day-to-Day: Paid from Back-Up Benefit

AHB Cover: GPs & Specialists in-hospital services paid up to a maximum of 200% of the NAMAF Tariff.

Benefit	Cover
Accommodation and Theatre	100%
Physiotherapy & Biokinetics (post-rehabilitation)	100%
MRI & CT Scans	100%
Internal Appliances & Materials	100%
Oncology – (All-inclusive In and Out of Hospital) Consultations and Procedures Hospitalisation Radiation Oncology (A referral is only acceptable from a medical specialist) Oncology Medication (Chemotherapy, Radiotherapy and Hormone Therapy)	100%
Dialysis/Organ Transplant	100%
Refractive Surgery	100%
Maternity Confinement – Full Procedure 12 Ante-natal Consultations per Beneficiary 6 Sessions, Ante / Post-natal Classes & Education 3 Sonar Scans per Beneficiary per Pregnancy	100% 100% 100% 100%

Day-to-Day Back-Up Benefit

Benefit	Cover
General Practitioners & Specialists	100% (Paid from Day-to-Day Back-Up Benefit)
Dentistry
Medicine & Injections
Optical
Primary Health Care Services
Auxiliary Services
Specified Illness Conditions

Contribution Tables

Emerald Plus Individual Contributions
Age Band		Main	Adult	Child
0	25	1,705	1,119	395
26	30	1,829	1,206	395
31	35	1,958	1,297	395
36	40	2,094	1,383	394
41	45	2,238	1,492	394
46	50	2,372	1,588	394
51	55	2,535	1,709	394
56	60	2,676	1,806	394
61	65	2,811	1,909	394
66+		2,960	2,006	394

Emerald Plus Group Contributions
Age Band		Main	Adult	Child
0	25	1,705	1,119	395
26	30	1,829	1,206	395
31	35	1,958	1,297	395
36	40	2,094	1,383	394
41	45	2,238	1,492	394
46	50	2,372	1,588	394
51	55	2,535	1,709	394
56	60	2,676	1,609	394
61	65	2,811	1,909	394
66+		2,920	2,006	394

OVERALL ANNUAL BENEFIT (OVERALL ANNUAL LIMIT)			N$1 081 600 per Beneficiary N$1 622 400 per Family
CATEGORY A: Benefits For Major Medical Expenses		% the NAMAF TARIFF	Pre-authorisation: 100% of the tariff will be paid out. Without Pre-authorisation: No benefit will be paid except in the case of emergency hospital admissions and after-hours emergencies, weekends and public holidays. OVERALL LIMIT
Additional Hospital Benefit Cover: GPs and Specialists In-Hospital services are paid up to a maximum of 200% of the NAMAF Tariff. OVERALL LIMIT
		COVER
1.	Hospitalisation	100%	Overall Annual Limit
	1.1 Accommodation & Theatre		Overall Annual Limit
	1.2 Accommodation in private wards (Difference between the general ward and private ward tariffs)		N$7 500 per Beneficiary N$16 500 per Family
	1.3. Intensive and high care (Maximum 3 days, then motivation)		Overall Annual Limit
	1.4. Blood transfusions
	1.5. Radiology & Pathology (in-hospital) Additional Hospital Benefit Cover is excluded
	1.6. Physiotherapy & Biokinetics Additional Hospital Benefit Cover is excluded
	1.6.1. Physiotherapy & Biokinetics (in-hospital)
	1.6.2. Physiotherapy & Biokinetics (post-rehabilitation) Additional benefit once the patient is out of the hospital 12 sessions/visits per Beneficiary (Benefit available within 3 months from hospital discharge) (Subject to prior approval)
	1.7. Medicine, fixed tariff procedures, hospital apparatus, and to take out medicine (7 days' supply only)
	1.8. Dialysis (Subject to Case Management and MHC Guidelines)
	1.9. Organ Transplant (Subject to Case Management and MHC Guidelines) Including medical expenses incurred by the donor if the recipient is a Fund member
	1.10. Internal Appliances & Materials (As per NMC protocol)	100% of the Cost
	1.11. Medical & Surgical Appliances (External)		Payable from the Day-to-day Back-Up Benefit
2.	General Practitioners and Specialists (in-hospital services) Additional Hospital Benefit Cover is included	200%	Overall Annual Limit
3.	Specialised Radiology Procedures (in & out of hospital) Additional Hospital Benefit Cover is excluded A referral is only acceptable from a medical specialist (a referral from GP acceptable in places where there is no medical specialist) (Subject to prior approval)	100%	Overall Annual Limit
	3.1 MRI & CT Scans		N$30 000 per Family
	3.2 Nuclear Medicine		Overall Annual Limit
4.	Maternity (Groups have cover from the date of joining. Individuals have a 9-month waiting period)	100%	Overall Annual Limit
	4.1 Confinement – Full Procedure		Overall Annual Limit
	4.2 Ante-natal Consultation 12 consultations per Beneficiary (Pro-rated from the date of joining) Additional Hospital Benefit cover is excluded		Payable from Maternity Benefit
	4.3 Ante-natal / Post-natal Classes & Education 6 sessions per Beneficiary (Pro-rated from the date of joining) Additional Hospital Benefit Cover is excluded
	4.4. Sonar Scans (excluding 3D) 3 scans per Beneficiary per Pregnancy Additional Hospital Benefit Cover is excluded
	4.5 Amniocentesis Additional Hospital Benefit Cover is excluded
	4.6 Midwifery Service Additional Hospital Benefit cover is excluded
5.	Insertion of Intrauterine Device w/ Hormone (all-inclusive) (Subject to prior approval)	100% the of Cost	N$6 500 per Beneficiary Overall Annual Limit
6.	Oncology (Subject to Case Management and MHC Guidelines)	100%	N$600 000 per Beneficiary Overall Annual Limit
	6.1. Consultations and procedures
	6.2. Hospitalisation
	6.3. Radiation oncology (A referral is only acceptable from a medical specialist)
	6.4. Oncology medication (chemotherapy, radiotherapy and hormone therapy)
	6.5. Hospitalisation and Related Procedures In-Hospital		Overall Annual Limit
7.	Refractive Surgery – All-inclusive (Subject to prior approval and MHC Guidelines) Groups have cover from the date of joining Individuals have a one-year waiting period	100%	N$6 200 per Beneficiary once-off N$7 500 per Family Overall Annual Limit
8.	Reconstructive Surgery (medical necessity only) (Subject to prior approval and subject to strict MHC guidelines)	100%	Overall Annual Limit
	8.1 Consultations and Procedures		N$6 750 per Family
	8.2 Hospitalisation		Overall Annual Limit
9.	Private Nursing/ Frail Care / Hospice (Subject to Case Management)	100%	N$21 750 per Family Overall Annual Limit
10.	Psychiatric Treatment – Hospitalisation (Subject to prior approval)	100%	N$32 750 per Family Overall Annual Limit
11.	Alcoholism/Drug Addiction (Subject to prior approval and MHC Guidelines)	100%	N$32 750 per Family Overall Annual Limit
12.	Specialised Dental Surgery - Additional Hospital Benefit cover is excluded (Subject to Pre-Authorisation)	100%	Overall Annual Limit
	12.1. Maxillo-Facial & Oral Surgery All-inclusive (trauma/non-elective) (Including dental extractions for children less than 10 years old and wisdom teeth extractions)		N$ 92 500 per Family
	12.2. Maxillo-Facial & Oral Surgery Hospitalisation (other/elective)		N$14 000 per Family
	12.3. Dental Implant – hospitalisation		N$14 000 per Family
	12.4. Maxillo-Facial & Oral Surgery – internal prosthesis (Excluding dental implant component)		Payable from Internal appliances under Hospital Benefit
13.	Stomal Therapy (all-inclusive) (Subject to prior approval)	100%	N$28 750 per Family Overall Annual Limit
14.	Ambulance & Evacuation Services (Subject to prior approval)	100%	Overall Annual Limit
	14.1. Emergency Ambulance & Flights (Territory: SADC countries) (Subject to prior approval)		Unlimited Benefit
	14.2. Ambulance/Inter-Hospital Transfer (Subject to prior approval)		Overall Annual Limit
15.	Medical Referral Subject to accommodation and travelling reimbursement protocols (Subject to prior approval)		Overall Annual Limit
	15.1. Transport	80% of the Cost	N$10 150 per Family
	15.2. Accommodation Other than a Recognised Hospital/Medical Institution (Maximum of 2 days)	100%	N$620 per day per Family
16.	International Medical Travel Insurance Medical cover when travelling to foreign countries For emergency cases only (not for elective surgery or procedure)	100% of the Cost	N$10 000 000 per Incident

CATEGORY B: DAY-TO-DAY BENEFIT		100% the Tariff	Limited to: N$6 300 Member only N$10 700 Member + Adult N$7 550 Member + Child N$11 950 Member + Adult + Child Additional N$ 1 250 benefit for each additional Child OVERALL ANNUAL LIMIT Benefits are prorated from the date of joining. Ex-Gratia is not applicable
Rules on Day-to-Day Back-up Benefit: Ninety-five per cent (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, 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 the principal member’s resignation from the fund, the principal member’s death or the principal member’s migration to a traditional option. The total amount is available for the family and is not limited per beneficiary.
17.	General Practitioners and Specialists (out-of-hospital, including casualties)	100%	Paid from Day-to-Day Back-Up Benefit
	17.1. Consultations/Visits
	17.2. Procedures/Services
	17.3. Materials and Disposable Items
	17.4. Radiology and Pathology (including radiography, sonography, medical laboratory technology and chemical biochemistry) (A referral is only acceptable from a medical practitioner)
18.	Medicine & Injections (Paid at the maximum Namibia Medicine Price List on generics)	100%	Paid from Day-to-Day Back-Up Benefit
	18.1. Acute Medicine & Injections
	18.2. Chronic Medicine & Injections
	18.3. Essential Vaccination / Immunisation (as per WHO guidelines
	18.4. Self Medication
19.	Primary Health Care Services Paid at the maximum Namibia Medicine Price List on generics	100%	Paid from Day-to-Day Back-Up Benefit
	19.1. Consultations and Procedures
	19.2. Medicine & Injections
20.	Dentistry	100%	Paid from Day-to-Day Back-Up Benefit
	20.1. Conservative & specialised dentistry (including dental therapy)
	20.2. Dental Implants (in-hospital & in-practice) (Pre-authorisation is required)
	20.3. Orthodontics (Prior approval required)
	20.4. Maxillo-Facial and Oral Surgery (in-hospital & in-practice)
21.	Optical	100%	Paid from Day-to-Day Back-Up Benefit
	21.1. Optical Tests
	21.2. Spectacles & lenses
	21.3. Frame
	21.4. Reader Spectacles
22.	Auxiliary Services (Supplementary Services)	100%	Paid from Day-to-Day Back-Up Benefit
	22.1. Art Therapy
	22.2. Audiology/Speech Therapy
	22.3. Biokineticist
	22.4. Chinese Medicine
	22.5. Chiropractor
	22.5.1. Consultation & procedure
	22.5.2. Medicine
	22.6. Clinical Psychology / Psychological Counsellor
	22.7. Clinical Technology
	22.8. Dietician
	22.9. Hearing Aid Acoustician
	22.10. Homeopathy/Naturopathy/ Phytotherapy
	22.10.1. Consultation & procedure
	22.10.2. Medicine
	22.11. Occupational Therapy
	22.12. Orthotist/Prosthetist
	22.13. Physiotherapy
	22.14. Podiatry/Chiropody
	22.15. Social Worker
23.	Medical & Surgical Appliances (External)	100% of the Cost	Paid from Day-to-Day Back-Up Benefit
24.	Specified Illness Conditions As per National Guidelines (Sub-limits are pro-rated from the date of joining)	100%	Paid from Day-to-Day Back-Up Benefit
	24.1. HIV/AIDS (As per the National Guidelines for Antiretroviral Therapy)
	24.1.1. Medicine (Paid at the maximum Namibia Medicine Price List on generics)
	24.1.2. First Full HIV Consultation / Assessment Once off benefit
	24.1.3. Consultation (after the first full HIV consultation/assessment) 6 consultations per Beneficiary
	24.1.4. HIV Counselling (Payable from Specified Illness Conditions)
	24.1.5. Pathology Tests (Payable from Specified Illness Conditions)
	24.1.6. HIV Resistance Test (Subject to prior approval)
	24.2. Prevention of Mother-to-Child Transmission (PMTCT)
	24.3. Post-Exposure Prophylaxis (PEP)
	24.4. Pre-Exposure Prophylaxis (PrEP)

Download Emerald Plus 2023 Detailed Benefits

Emerald Plus - Our Benefits - Options & Benefits | NMC

Key Benefits

Day-to-Day Back-Up Benefit

Contribution Tables

Announcements

Emerald Plus - Our Benefits - Options & Benefits | NMC

Key Benefits

Day-to-Day Back-Up Benefit

Contribution Tables

Announcements ×

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Announcements