Options and Benefits Terms Simplified

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.

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.

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.

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.

Radiology and Pathology (day-to-day benefit) – a referral from a medical practitioner is required.

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.