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	1,936	1,270	448
26	30	2,076	1,369	448
31	35	2,223	1,472	448
36	40	2,378	1,570	447
41	45	2,541	1,694	447
46	50	2,693	1,803	447
51	55	2,879	1,940	447
56	60	3,039	2,051	447
61	65	3,191	2,167	447
66+		3,361	2,278	447

Group Contributions
Age Band		Main	Adult	Child
0	25	1,936	1,270	448
26	30	2,076	1,369	448
31	35	2,202	1,417	448
36	40	2,321	1,479	447
41	45	2,435	1,577	447
46	50	2,583	1,684	447
51	55	2,645	1,738	447
56	60	2,759	1,829	447
61	65	2,935	1,946	447
66+		2,988	1,984	447

OVERALL ANNUAL BENEFIT (OVERALL ANNUAL LIMIT)			N$1 575 000 per Beneficiary N$1 890 000 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$7 500 per Beneficiary N$16 500 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$5 250 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$31 500 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$6 800 per Beneficiary Overall Annual Limit
6.	Oncology (Subject to Case Management and MHC Guidelines)	100%	N$630 000 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.	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$14 550 per Beneficiary once-off N$18 650 per Family
	7.2. Cataract Surgery and Lens Implants		N$19 700 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$7 100 per Family
	8.2. Hospitalisation		Overall Annual Limit
9.	Private Nursing/Frail Care/Hospice (Subject to Case Management)	100%	N$22 850 per Family Overall Annual Limit
10.	Psychiatric Treatment – Hospitalisation (Subject to prior approval)	100%	N$34 500 per Family Overall Annual Limit
11.	Alcoholism/Drug Addiction (Subject to prior approval and MHC Guidelines)	100%	N$34 500 per Family Overall Annual Limit
12.	Specialised Dental Surgery Additional Hospital Benefit cover excluded (Subject to pre-authorisation)	100%	Overall Annual Limit
	12.1. Maxillo-Facial and Oral Surgery (trauma/non-elective) All-inclusive		N$ 97 150 per Family
	12.2. Maxillo-Facial and Oral Surgery (Including Dental Implants) (other/elective) All-inclusive		N$30 750 per Beneficiary N$38 100 per Family N$5 000 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$28 750 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$5 780 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$10 150 per Family
	15.2. Accommodation Other than a Recognised Hospital/Medical Institution (Maximum of two 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 Cost	N$10 000 000 per Incident
17.	Lifestyle Management Screening Tests (Subject to Clinical Guidelines and Protocols)	100%	N$15 000 per Family

CATEGORY B: DAY-TO-DAY BACKUP BENEFIT		100% Tariff	Limited to: N$8 050 member only N$13 700 Member + Adult N$9 650 Member + Child N$15 300 Member + Adult + Child Additional N$1 600 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.
17.	General Practitioners and Specialists (out-of-hospital, including casualties)	100%	Paid from Day-to-Day Back-Up Benefit
	17.1. Consultations/Visits (Including General Practitioner virtual/telephonic consultations)
	17.2. Procedures/Services
	17.3. Materials and Disposable Items
	17.4. Radiology and Pathology (Including Radiography, Sonography, Medical Laboratory Technology and Chemical Biochemistry) (Referral from a medical practitioner)
18.	Medicine and Injections (Paid at the maximum Namibia medicine price list on generics)	100%	Paid from Day-to-Day Back-Up Benefit
	18.1. Acute Medicine and Injections
	18.2. Chronic Medicine and 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 and Injections
20.	Dentistry	100%	Paid from Day-to-Day Back-Up Benefit
	20.1. Conservative and Specialised Dentistry (Including Dental Therapy)
	20.2. Maxillo-Facial, Oral Surgery and Dental Implants In-practice consultations and non-surgical procedures
	20.3. Orthodontics (Subject to prior approval and MHC Guidelines)
21.	Optical	100%	Paid from Day-to-Day Back-Up Benefit
	21.1. Optical Tests
	21.2. Spectacles and 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 and procedure
	22.5.2. Medicine
	22.6. Clinical Psychology/Psychological Counsellor
	22.7. Clinical Technology
	22.8. Dietician
	22.9. Hearing Aid Acoustician
	21.10. Homeopathy/Naturopathy/Phytotherapy
	22.10.1. Consultation and 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 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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