Emerald Plus

Key Benefits

Hospital: Major medical expenses

AHB Cover: GPs and specialists in-hospital services payable to a maximum of 150% of the NAMAF tariff

Benefit	Cover
Accommodation and Theatre	100%
Physiotherapy and Biokinetics (In-hospital)	100%
Post Rehabilitation Physiotherapy, Biokinetics and Occupational Therapy	100%
MRI and CT Scans	100%
Internal Appliances and Materials	100% of Cost
Oncology Consultations and Procedures Out-of-Hospital MRI/CT Scans and Other Specialised Radiology Procedures In and Out-of-Hospital Radiation Oncology (Referral from a medical specialist only) Oncology Medication (Chemotherapy, radiotherapy and hormone therapy) Hospitalisation and Related Procedures In-Hospital	100%
Dialysis/Organ Transplant	100%
Corrective Eye Surgery – All-inclusive Refractive Surgery Cataract Surgery and Lens Implants	100%
Maternity - Confinement – Full Procedure Confinement – full procedure 12 Ante-natal consultations per Beneficiary Six sessions, ante-/post-natal classes and education Three sonar scans per Beneficiary per pregnancy	100%

Day-to-Day Benefits

Benefits are paid from the Day-to-Day Back-Up benefit.

Benefit	Cover
General Practitioners and Specialists	100%
Dentistry
Medicine and Injections
Optical
Primary Health Care Services
Auxiliary Services
Specified Illness Conditions

Contribution Tables

Individual Contributions
Age Band		Main	Adult	Child
0	25	2,023	1,327	468
26	30	2,169	1,431	468
31	35	2,323	1,538	468
36	40	2,485	1,641	467
41	45	2,655	1,770	467
46	50	2,814	1,884	467
51	55	3,009	2,027	467
56	60	3,176	2,143	467
61	65	3,335	2,265	467
66+		3,512	2,381	467

Group Contributions
Age Band		Main	Adult	Child
0	25	2,023	1,327	468
26	30	2,169	1,431	468
31	35	2,301	1,481	468
36	40	2,425	1,546	467
41	45	2,545	1,648	467
46	50	2,699	1,760	467
51	55	2,764	1,816	467
56	60	2,883	1,911	467
61	65	3,067	2,034	467
66+		3,122	2,073	467

OVERALL ANNUAL BENEFIT (OVERALL ANNUAL LIMIT)			N$1 630 125 per Beneficiary N$1 956 150 per Family
CATEGORY A: Benefits For Major Medical Expenses		% NAMAF Tariff	Pre-authorisation: 100% of the tariff will be paid. 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 150% of the NAMAF tariff. OVERALL LIMIT
		COVER
1.	Hospitalisation	100%	Overall Annual Limit
	1.1. Accommodation and Theatre		Overall Annual Limit
	1.2. Accommodation in private wards (Difference between the general ward and private ward tariffs)		N$7 700 per Beneficiary N$17 080 per Family
	1.3. Intensive and high care (Maximum three days, then motivation)		Overall Annual Limit
	1.4. Blood transfusions
	1.5. Radiology and Pathology (in-hospital) Additional Hospital Benefit Cover excluded
	1.6. Physiotherapy and Biokinetics Additional Hospital Benefit Cover excluded (Subject to prior approval)
	1.7. Post Rehabilitation Physiotherapy, Biokinetics and Occupational Therapy Additional Hospital Benefit Cover excluded Additional benefit once the patient is out of hospital or transferred to rehabilitation facility Benefit available within three months from hospital discharge (Subject to prior approval)		N$5 435 per Beneficiary Overall Annual Limit
	1.8. Medicine, fixed tariff procedures, hospital apparatus, and to take out medicine (Seven days' supply only)		Overall Annual Limit
	1.9. Dialysis (Subject to Case Management and MHC Guidelines)
	1.10. Organ Transplant (Subject to Case Management and MHC Guidelines) Including medical expenses incurred by the donor if the recipient is a Fund member
	1.11. Internal Appliances and Materials (As per NMC protocol)	100% of Cost
	1.12. Medical and 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 except the use of equipment and equipment hire fees	100%	Overall Annual Limit
3.	Specialised Radiology Procedures (in and out of hospital) Additional Hospital Benefit Cover is excluded A referral is only acceptable from a medical specialist (a referral from a GP acceptable in places where there is no medical specialist) (Subject to prior approval)	100%	Overall Annual Limit
	3.1 MRI and CT Scans		N$32 600 per Family
	3.2 Nuclear Medicine		Overall Annual Limit
4.	Maternity (Groups have cover from the date of joining. Individuals have a nine-month waiting period)	100%	Overall Annual Limit
	4.1 Confinement – Full Procedure		Overall Annual Limit
	4.2 Antenatal Consultation 12 consultations per Beneficiary (Prorated from the date of joining) Additional Hospital Benefit cover is excluded		Payable from Maternity Benefit
	4.3 Antenatal/Post-natal Classes and Education Six sessions per Beneficiary (Prorated from the date of joining) Additional Hospital Benefit cover excluded
	4.4. Sonar Scans (excluding 3D) Three scans per Beneficiary per Pregnancy Additional Hospital Benefit cover excluded
	4.5. Amniocentesis Additional Hospital Benefit cover excluded
	4.6. Midwifery Service Additional Hospital Benefit cover excluded
5.	Insertion of Intrauterine Device w/ Hormone (all-inclusive) (Subject to prior approval) (Benefit is prorated from the date of joining)	100% of Cost	N$7 040 per Beneficiary Overall Annual Limit
6.	Oncology (Subject to Case Management and MHC Guidelines)	100%	N$652 050 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.	Corrective Eye 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%	Overall Annual Limit
	7.1. Refractive Surgery		N$15 100 per Beneficiary once-off N$19 350 per Family
	7.2. Cataract Surgery and Lens Implants		N$20 390 per eye per Beneficiary once-off
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$7 350 per Family
	8.2. Hospitalisation		Overall Annual Limit
9.	Private Nursing/Frail Care/Hospice (Subject to Case Management)	100%	N$23 650 per Family Overall Annual Limit
10.	Psychiatric Treatment (Subject to prior approval)		Overall Annual Limit
	10.1 Consultation and Procedures		Sub-limit 10
	10. 2 Hospitalisation	100%	N$35 710 per Family Sub-Limit 10
11.	Alcoholism/Drug Addiction (Subject to prior approval and NMH guidelines)	100%	Sub-Limit 10.2
12.	Specialised Dental Surgery Additional Hospital Benefit cover excluded (Subject to pre-authorisation)	100%	Overall Annual Limit
	12.1. Maxillo-Facial and Oral Surgery (trauma/non-elective) All-inclusive		N$ 100 600 per Family
	12.2. Maxillo-Facial and Oral Surgery (Including Dental Implants) (other/elective) All-inclusive		N$31 850 per Beneficiary N$39 435 per Family N$5 175 for all dental implant components per tooth
	12.3. Maxillo-Facial and Oral Surgery (Including Dental Implants) In-practice (performed in a doctor’s room) Procedures only	150%	Payable from maxillo-facial, oral surgery and dental implants (other/elective)
	12.4. Maxillo-Facial and Oral Surgery - Internal Prosthesis (excluding dental implant component)	100%	Payable from Internal appliances under Hospital Benefit
13.	Stomal Therapy (all-inclusive) (Subject to prior approval)	100%	N$29 800 per Family Overall Annual Limit
14.	Ambulance and 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)		N$5 985 per Beneficiary
15.	Medical Referral Subject to accommodation and travelling reimbursement protocols (Subject to prior approval)		Overall Annual Limit
	15.1. Transport	70% of Cost	N$10 510 per Family
	15.2. Accommodation Other than a Recognised Hospital/Medical Institution (Maximum of two days)	100%	N$642 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 Cost	N$10 000 000 per Incident
17.	Lifestyle Management Screening Tests (Subject to Clinical Guidelines and Protocols)	100%	N$15 000 per Family
	17.1 Screening Tests		Sub-limit 17
	17.2 Rapid Tests		N$ 1 500 per Family Sub-limit 17

CATEGORY B: DAY-TO-DAY BACKUP BENEFIT		100% Tariff	Limited to: N$8 600 member only N$14 600 Member + Adult N$10 250 Member + Child N$16 300 Member + Adult + Child Additional N$1 650 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 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, 95% of the unused benefit will be accumulated 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.
18.	General Practitioners and Specialists (out-of-hospital, including casualties)	100%	Paid from Day-to-Day Back-Up Benefit
	18.1. Consultations/Visits (Including General Practitioner virtual/telephonic consultations)
	18.2. Procedures/Services
	18.3. Materials and Disposable Items
	18.4. Radiology and Pathology (Including Radiography, Sonography, Medical Laboratory Technology and Chemical Biochemistry) (Referral from a medical practitioner)
19.	Medicine and Injections (Paid at the maximum Namibia medicine price list on generics)	100%	Paid from Day-to-Day Back-Up Benefit
	19.1. Acute Medicine and Injections
	19.2. Chronic Medicine and Injections
	19.3. Essential Vaccination/Immunisation (as per WHO guidelines)
	19.4. Self Medication
20.	Primary Health Care Services (Paid at the maximum Namibia medicine price list on generics)	100%	Paid from Day-to-Day Back-Up Benefit
	20.1. Consultations and Procedures
	20.2. Medicine and Injections
21.	Dentistry	100%	Paid from Day-to-Day Back-Up Benefit
	21.1. Conservative and Specialised Dentistry (Including Dental Therapy)
	21.2. Maxillo-Facial, Oral Surgery and Dental Implants In-practice consultations and non-surgical procedures
	21.3. Orthodontics (Subject to prior approval and MHC Guidelines)
22.	Optical	100%	Paid from Day-to-Day Back-Up Benefit
	22.1. Optical Tests
	22.2. Spectacles and Lenses
	22.3. Frame
	22.4. Reader Spectacles
23.	Auxiliary Services (Supplementary Services)	100%	Paid from Day-to-Day Back-Up Benefit
	23.1. Art Therapy
	23.2. Audiology/Speech Therapy
	23.3. Biokineticist
	23.4. Chinese Medicine
	23.5. Chiropractor
	23.5.1. Consultation and procedure
	23.5.2. Medicine
	23.6. Clinical Psychology/Psychological Counsellor
	23.7. Clinical Technology
	23.8. Dietician
	23.9. Hearing Aid Acoustician
	23.10. Homeopathy/Naturopathy/Phytotherapy
	23.10.1. Consultation and Procedure
	23.10.2. Medicine
	23.11. Occupational Therapy
	23.12. Orthotist/Prosthetist
	23.13. Physiotherapy
	23.14. Podiatry/Chiropody
	23.15. Social Worker
24.	Medical and Surgical Appliances (External) (Subject to MHC Guidelines)	100% of Cost	Paid from Day-to-Day Back-Up Benefit

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Emerald Plus - Our Benefits - Options and Benefits | NMC

Key Benefits

Day-to-Day Benefits

Contribution Tables

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Emerald Plus - Our Benefits - Options and Benefits | NMC

Key Benefits

Day-to-Day Benefits

Contribution Tables

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