The
following explanations of the benefits available under NMC should be read in
conjunction with the benefits options, for clarity:
AHB
cover pays the excess that is charged over and above the tariff covered by the
benefits for general practitioners and/or specialists if a member is
hospitalised.
The Fund pays 100% of NAMAF tariff PLUS a maximum of 125% additional cover for any excess of tariff that general practitioners and specialists may charge.
AHB is included for the following in-hospital services:
AHB is excluded for the following in-hospital services:
The Fund pays 100% of NAMAF tariff PLUS a maximum of 125% additional cover for any excess of tariff that general practitioners and specialists may charge.
AHB is included for the following in-hospital services:
- General Practitioner and Specialists
AHB is excluded for the following in-hospital services:
- Radiology and Pathology
- Specialised Radiology Procedures Ante-natal Consultation
- Maternity: Sonar Scans
- Maternity: Amniocentesis Maternity: Midwifery Service
They are
all paid in accordance to the Maximum Namibia Medicine Price List on generics.
This means that the Fund only pays the equivalent of the generic medication that is prescribed by your doctor or dispensed by your pharmacist in an effort to encourage practitioners and members to make use of generic medication which has the same composition of the branded medication, but is better priced.
The Fund will cover the branded medication where there is no generic available or where a health professional writes a motivation to pay for the branded medication.
Vaccinations and Immunisations are also paid according to the internationally accepted World Health Organisation guidelines.
This means that the Fund only pays the equivalent of the generic medication that is prescribed by your doctor or dispensed by your pharmacist in an effort to encourage practitioners and members to make use of generic medication which has the same composition of the branded medication, but is better priced.
The Fund will cover the branded medication where there is no generic available or where a health professional writes a motivation to pay for the branded medication.
Vaccinations and Immunisations are also paid according to the internationally accepted World Health Organisation guidelines.
The
benefit includes all medical costs relating to the procedures, including
medicine and materials, hospital, medical practitioner’s fees, anaesthetic
service, nursing service and all other health care providers involved before,
during and/or after the procedures.
The following benefits are subject to prior approval, managed healthcare guidelines or case management on all options (except Topaz and Topaz Plus) by Managed Healthcare. Please contact the Managed Healthcare Department at: 061-287 6179 or email: mhc@methealth.com.na for more information.
The following benefits are subject to prior approval, managed healthcare guidelines or case management on all options (except Topaz and Topaz Plus) by Managed Healthcare. Please contact the Managed Healthcare Department at: 061-287 6179 or email: mhc@methealth.com.na for more information.
Benefit | Requires Prior Approval | Subject to Managed Healthcare Guidelines | Case Management |
---|---|---|---|
Accommodation other than a hospital / medical institution | √ | √ | |
Specialised Radiology Procedures | √ | ||
Dialysis | √ | √ | √ |
Oncology | √ | √ | √ |
Organ Transplant (including medical expenses incurred by donor who is a member of NMC) | √ | √ | √ |
Refractive Surgery (All-Inclusive) | √ | √ | |
Reconstructive Surgery | √ | √ | |
Private Nursing | √ | √ | |
Frail Care | √ | √ | |
Alcoholism / Drug Addiction | √ | √ | |
Psychiatric Treatment | √ | ||
Specialised Dentistry – Hospitalisation | √ | ||
Insertion of Intrauterine Device with Hormone | √ | ||
Stomaltherapy (All-Inclusive) | √ | ||
Emergency Ambulance and Flights | √ | ||
Ambulance / Inter-hospital transfer | √ | ||
Other transport | √ | ||
Dental Implants | √ | ||
Maxillo-Facial and Oral Surgery | √ | ||
Wheelchair | √ | ||
Artificial Limbs | √ | ||
Artificial Eyes | √ | ||
External Appliances | √ | √ | |
Hearing Aid Apparatus | √ | ||
HIV Resistance Test | √ |
The
Benefit Booster is a supplementary benefit on certain day-to-day medical
services where normal benefit limits have been exceeded. The Benefit Booster is
only applicable to the Diamond, Sapphire, Ruby and Opal options.
This
function ensures that a collaborative process is followed to assess, plan,
implement, monitor and evaluate the treatment the member receives. Frequent intervention
takes place to ensure that the member receives the treatment as prescribed by
the healthcare professional. All benefits that are subject to Case Management
require prior approval
Consultations
and procedures are included in the Dental Implant Benefit. It is important to
note that the Dental Implant Benefit is for a procedure in the hospital OR in
the practice, but not for both. The maximum cost per dental implant component
is N$3 500 on Ruby, Sapphire and Diamond.
Please
note that all out-of-hospital and casualty cases (when you visit the hospital
as an out-patient after hours) are included in the general practitioners and
specialist day-to-day consultations/visits and procedures/services.
The
Hearing Aid Apparatus and Wheelchair benefits are inclusive of any repair and
maintenance costs that may arise.
The
HIV/AIDS benefits are paid in line with the national guidelines for
antiretroviral therapy.
The International Medical Travel Insurance makes
provision for emergency medical expenses whilst NMC
members and/or their dependents are traveling. The
cover is limited to N$ 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.
This benefit is not applicable to Topaz Plus and Topaz members. Apply for your travel certificate before you embark on your trip.
The Fund
has its own set of accepted guidelines to ensure that each member receives the
appropriate treatment, at the agreed cost, and that the process is properly
managed from an administrative perspective. Certain complicated procedures are
therefore subject to these guidelines. All benefits that are subject to Managed
Health Care guidelines require prior approval.
Motivations
and referrals are required for some services from the Fund. This is to ensure
that the treatment fits the parameters of the NMC definition of a medical
necessity in some high-cost or unique cases. Motivations are required from
members for the following services/ benefits:
- Intensive and High Care – a member can be hospitalised for three days, where after a motivation is required from the medical practitioner
- Specialised Radiology Procedures (in and out of hospital) – a referral from a medical specialist is required. A referral from a GP will be acceptable only in towns where there are no medical specialists available.
Pre-authorisation
needs to be given for some benefits before the service is rendered by a health
professional or the appliance is supplied to ensure that there is a sufficient
benefit. This also assists the member in financial planning for all expenses
involved in the treatment needed.
When an
individual member joins the Fund, there is a waiting period on certain benefits
and pro-rated benefits on others. This is implemented to protect the Fund and
its members from those who have not contributed premiums over a longer period
who want to have a specific (sometimes expensive) procedure performed and then
resign from the Fund.
Waiting periods are not applicable to members who join the Fund as part of the Employer Group.
Waiting periods are not applicable to members who join the Fund as part of the Employer Group.