2020 Benefit Guide


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BENEFIT GUIDE 2020

MEMBER COMMUNICATION

3

TOPAZ & TOPAZ PLUS

8

OPAL & JADE

16

RUBY & SAPPHIRE

25

EMERALD & AMBER

36

EMERALD 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.
ACCESSIBLE INFORMATION/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 dayto-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 Insurance
The 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 Evacuation
The 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 lifesustaining conditions that require emergency transport are covered.
3. Premium Waiver
The 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 Parents
The 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 Booster
The 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 Policy
Ex 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 Services
NMC 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 Programme
NMC 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://nmcfundchallenges.com/ for more information) • Participation in social runs in conjunction with Windhoek City Runners.
A CLIENT SERVICE OFFICE IN YOUR AREA
NMC 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 Park Phone: (061) 287 6000/6001/6006/6061 Fax (061) 287 6091 E-mail: [email protected]
For Health Professionals Email: [email protected]
MMI House Phone: (061) 297 3222 Fax: (061) 294 7352 E-mail: [email protected]
Walvis Bay Branch Phone: (064) 200 563/200 276/200 253 Fax: (064) 200 376 E-mail: [email protected]
Swakopmund Branch Phone: (064) 402 529 Fax: (064) 405 235 E-mail: [email protected]
Tsumeb Branch Phone: (067) 221 767 Fax: (067) 222 812 E-mail: [email protected]
Lüderitz Branch Phone: (063) 203 525 Fax: (063) 203 561 E-mail: [email protected]

Oshakati Branch Phone: (065) 220 774 / 177 Fax: (065) 220 779 E-mail: [email protected]
Rundu Branch Phone: (066) 255 035 / 267 344 Fax: (066) 255 607 [email protected]
Ondangwa Branch Phone: (065) 240 409 Fax: (065) 240 155 Fax: (063) 234 146 Email: [email protected]
Rosh Pinah Branch Phone: (063) 274 901 Fax: (063) 274 902 E-mail: [email protected]
Oranjemund Branch Phone: (063) 234 140 Fax: (063) 234 146 Email: [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 & Trustees Namibia Medical Care

Namibia Medical Care | 2020 Benefit Guide 5

6 Namibia Medical Care | 2020 Benefit Guide

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.

Emergency Evacuation/Ambulance Providers Namibia

DISCIPLINE ALS ALS ALS
ALS
ALS
ALS
ECT
ALS + ILS
ECT ILS + ECT ILS ILS ILS
ILS ALS

EMERGENCY EVACUATION PROVIDER AEMS Ambulance Services City of Windhoek Emergency Services Code Red Medical Services
Crisis Response
Okahandja Paramedical Services
Lifelink Emergency Services
Mr 24/7
Namibia Private Ambulance Services
Intensive Therapy Unit Ambulance Services Outapi Ambulance Ohangwena Private Ambulance Services Ondangwa Ambulance Services Rosh Pinah Clinic Ambulance Service
St. Gabriel Community Ambulance Trust E-Med Rescue 24

EMERGENCY CONTACT NUMBER 081 963 061 211 111 085 99 00 085 705 8940 (from cell)
085 99 00 085 705 8940 (from cell)
987
999 (from any landline) 085 900 (from cell) 085 956 (061) 255 676 081 9696
081 444 7807 065 251 022/ 251 800 081 9797 081 90 200 063 274 918/ 081 161 8734 085 955/ 081 124 5999 081 924

MAIN AREA OF COVERAGE Windhoek & Surrounding Areas Windhoek & Surrounding Areas Coast (Arandis, Walvis Bay, Swakopmund & Henties Bay) or as per request
Coast (Arandis, Walvis Bay, Swakopmund & Henties Bay) or as per request
Okahandja & Surrounding Areas
Windhoek & Long Distance Countrywide
Rehoboth, Windhoek, Otjiwarongo, Tsumeb & Mercy Flights Countrywide Outapi, Ongwediva Rundu & Ondangwa & Long Distance Countrywide Eenhana & Long Distance Countrywide Outapi, Oshakati & Surrounding Areas Grootfontein, Windhoek, Katima & Tsumeb Ondangwa & Countrywide Rosh Pinah & Oranjemund
Walvis Bay & Swakopmund All Major Cities & Air Ambulance Evacuation Countrywide

ALS - Advanced Life Support Service

ILS - Intermediate Life Support Service

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

ECT - Emergency Care Support Technician Service

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

OVERALL ANNUAL BENEFIT (OVERALL ANNUAL LIMIT)
CATEGORY A: Primary Healthcare Benefits
1. Nurse 1.1. Consultations / Visits
1.2. Medication / Injections
1.3. Procedures 2. General Practitioner
2.1. Consultations / Visits (Out-Of-Hospital)
2.2. Acute Medication / Injections (Paid at Maximum Namibia Medicine Price on generics)
2.3. Chronic Medication/Injections -- Subject to Chronic Medication Registration (Paid at Maximum Namibia Medicine Price on generics)
2.4. Procedures (out-of-hospital)
3. Medical Specialists Consultations / Visits
4. Pharmacy 4.1. Acute Medication / Injections (Paid at Maximum Namibia Medicine Price on generics) 4.2. Chronic Medication / Injections -- Subject to Chronic Medication Registration (Paid at Maximum Namibia Medicine Price on generics)
5. Pathology
6. Radiology

TOPAZ

TOPAZ PLUS

% Tariffs
100%
100%

Unlimited According to Defined Primary Healthcare Protocols

Registered Nurse
Unlimited Unlimited (According to Topaz & Topaz Plus Medicine Formulary) Unlimited According to defined protocols Unlimited (0101 & 0108 only)
(According to Topaz and Topaz Plus Acute Medicine Formulary)

Registered Nurse Unlimited
Unlimited. (According to Topaz and Topaz Plus Medicine Formulary) Unlimited
According to defined protocols Unlimited
(According to Topaz and Topaz Plus Acute Medicine Formulary)

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

100% 100% 100%

Unlimited According to defined protocols
No Benefit Unlimited
(According to Topaz and Topaz Plus Acute Medicine Formulary)

No Benefit
5 per Family per annum (0101 and 0108 only) Unlimited
(According to Topaz and Topaz Plus Acute Medicine Formulary)

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

Specified Tests
Long bones, chest and trauma and basic radiology as per defined list
(Excluding MRI & CT Scan)

Specified tests
Long bones, chest and trauma and basic radiology as per defined list
(Excluding MRI & CT Scan)

8 Namibia Medical Care | 2020 Benefit Guide

7. Dentistry
8. Optical
8.1. Single Vision (Inclusive of Test, Frame and Lenses 8.2. Bifocal (Inclusive of Test, Frame and Lenses)
(Paid at Maximum Namibia Medicine Price on generics)
9. Sonar Scans

100% 100%
100%

10. Ante-natal Consultation (General Practitioner)
11. Paramedical / Allied Health Professionals (Psychologists, Physiotherapists, Occupational Therapists)
CATEGORY B: HIV/AIDS Treatment
12. HIV/AIDS Treatment 12.1. Consultations (General Practitioners)

100% 100%
% Tariffs

12.2. Medication (including vitamins & supplements)
12.3. Pathology 12.4. Counselling (pre-, post & adherence) 12.5. Post Exposure Prophylaxis (PEP) (Rape Cover
only) 12.6. Pre-Exposure Prophylaxis (PrEP) 12.7. Prevention of Mother-to Child Transmission
(PMTCT) (excluding milk formula)

100%

Extractions and Fillings Only No Benefit No Benefit

Extractions, fillings & 2 oral hygiene visits per beneficiary including pain and sepsis as per defined list.
N$1 000 per beneficiary every two years (2019/2020) (6 months waiting period, complete test, specified frames and
lenses)
Sub-limit 8

No Benefit
3 scans per Beneficiary per pregnancy 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 joining Individuals have 9-month waiting period

Sub-limit 8
3 scans per Beneficiary per pregnancy Groups have cover from date of joining Individuals have a 9-month waiting period
Limited to 6 consultations per Beneficiary (2601 & 2602)
Groups have cover from date of joining Individuals have a 9-month waiting period

No Benefit

3 consultations / sessions per Family per annum

Unlimited According to Defined Protocols Benefits available only at Network Health Professionals

As per National Guidelines for Antiretroviral Therapy

As per National Guidelines for Antiretroviral Therapy

6 consultations per beneficiary (including the first full HIV consultation)

Unlimited

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)

Unlimited

Unlimited

3 Sessions

3 Sessions

As per National Guidelines for Antiretroviral Therapy

As per National Guidelines for Antiretroviral Therapy

No Benefit

No Benefit

As per National Guidelines for Antiretroviral Therapy

As per National Guidelines for Antiretroviral Therapy

Namibia Medical Care | 2020 Benefit Guide 9

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

13. Hospitalisation
13.1. Accommodation and Theatre
13.2. Blood Transfusions 13.3. Intensive and High Care (3 days then referral to
State Hospitals) 13.4. Medicine, Fixed Tariff Procedures, Hospital
Apparatus and To Take Out Medicine
13.5. Radiology & Pathology (In-Hospital)
14. General Practitioners & Medical Specialists (InHospital services)
-- Additional Hospital Benefit Cover excluded 15. Other Healthcare Providers

100%
100% 100%

Unlimited
Overall Annual Limit Overall Annual Limit Overall Annual Limit Overall Annual Limit
Sub-limit 14 N$25 000 per Family Overall Annual Limit
No Benefit

N$115 000 per family 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.
Overall Annual Limit 15 days per Beneficiary
Overall Annual Limit
Overall Annual Limit
Overall Annual Limit (Limited to 7 days’ supply only)
N$3 000 per Family Sub-limit 14
N$25 000 per Family (Including Radiology and Pathology)
Overall Annual Limit
No Benefit

16. Maternity

17. Ambulance Services
17.1. Emergency Road Ambulance* (Territory: SADC Countries) (Subject to pre-approval)

100%

Unlimited Hospitalisation in State Hospital (GPs and Specialists limited to Sub-Limit 14)
Groups have cover from date of joining Individuals have a 9-month waiting period
Unlimited

Unlimited Hospitalisation in State Hospital (GPs and Specialists limited to Sub-Limit 14)
Groups have cover from date of joining Individuals have a 9-month waiting period.
Unlimited

17.2. Ambulance/Inter-hospital Transfer* (Subject to pre-approval)

N$550 per Family

N$550 per Family

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2020 Benefit Guide