Our Benefits - Options and Benefits

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%
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

Benefit	Cover
General Practitioners and Specialists	100%
Medicine and Injections Acute and Chronic Essential Vaccination/Immunisation (As per WHO guidelines) Self-Medication	100%
Primary Health Care Services	100%
Dentistry	100%
Optical	100%
Auxiliary Services	100%

Contributions

Individuals
Age Band		Main	Adult	Child
0	25	2,068	1,287	573
26	30	2,288	1,447	573
31	35	2,492	1,626	573
36	40	2,793	1,839	585
41	45	3,058	2,016	585
46	50	3,277	2,204	585
51	55	3,566	2,430	585
56	60	3,803	2,608	585
60	65	4,048	2,788	585
66+		4,296	2,990	585

Groups
Income Band		Main	Adult	Child
0	4,360	1,862	1,205	344
4,361	5,760	2,144	1,368	394
5,761	8,810	2,296	1,419	424
8,811	12,950	2,360	1,522	434
12,951	14,550	2,640	1,691	487
14,551	16,500	2,924	1,861	540

OVERALL ANNUAL BENEFIT (OVERALL ANNUAL LIMIT)			N$474 750 Per Beneficiary N$712 400 Per Family
Category A: Hospital Benefit		% 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.
Additional Hospital Benefit Cover: GPs and specialists in-hospital services are paid up to a maximum of 150% of the NAMAF tariff. OVERAL 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)		No Benefit
	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$3 500 per Beneficiary Overall Annual Limit
	1.8. Medicine, fixed tariff procedures, hospital apparatus, and to take out medicine (Seven days' supply only)		Overall Annual Limit
	1.9. Dialysis (Subject to Case Management and MHC Guidelines)
	1.10. Organ Transplant (Subject to Case Management and MHC guidelines) Including medical expenses incurred by the donor if the recipient is a Fund member
	1.11. Internal Appliances and Material (As per NMC protocol)	100% of Cost
2.	General Practitioners and Specialists (In-Hospital Services) Additional Hospital Benefit Cover is included except the use of equipment and equipment hire fees	100%	N$ 36 100 per Family 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 (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$16 600 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 the Maternity Benefit
	4.3. Ante/Postnatal Classes and Education Six sessions per Beneficiary (Prorated from the date of joining) Additional Hospital Benefit Cover is excluded
	4.4. Sonar Scans Three scans per Beneficiary per Pregnancy Additional Hospital Benefit Cover is excluded
	4.5. Amniocentesis Additional Hospital Benefit Cover is excluded
	4.6. Midwifery Service Additional Hospital Benefit Cover is excluded
5.	Insertion of Intrauterine Device with Hormone (All-inclusive) (Subject to prior approval) (Prorated from the date of joining)	100%	N$6 500 per Beneficiary Overall Annual Limit
6.	Oncology (Subject to Case Management and MHC Guidelines)	100%	N$350 000 per Beneficiary Overall Annual Limit
	6.1. Consultation and Procedures Out-of-Hospital
	6.2. MRI/CT Scans and Other Specialised Radiology Procedures In and Out-of-Hospital Additional Hospital Benefit Cover is excluded A referral is only acceptable from a medical specialist
	6.3. Radiation Oncology (Referral from a medical specialist only)
	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%	No Benefit
	7.1. Refractive Surgery
	7.2. Cataract Surgery and Lens Implants
8.	Reconstructive Surgery (medical necessity only)	100%	No Benefit
9.	Private Nursing/Frail Care/Hospice (Subject to Case Management)	100%	N$8 300 per Family Overall Annual Limit
10.	Psychiatric Treatment - Hospitalisation (Subject to prior approval)	100%	N$32 750 per Family Overall Annual Limit
11.	Alcoholism/Drug Addiction (Subject to prior approval and MHC guidelines)	100%	N$32 750 per Family Overall Annual Limit
12.	Specialised Dental Surgery Additional Hospital Benefit cover excluded (Subject to pre-authorisation)	100%	No Benefit
	12.1. Maxillo-Facial and Oral Surgery (trauma/non-elective) All-inclusive
	12.2. Maxillo-Facial, Oral Surgery and Dental Implants All-inclusive
13.	Stomal Therapy (All-inclusive) (Subject to prior approval)	100%	N$17 000 per Family Overall Annual Limit
14.	Ambulance and Evacuation Services	100%	Overall Annual Limit
	14.1. Emergency ambulance and Flights (Territory: SADC Countries) (Subject to Prior Approval)		Unlimited Benefit
	14.2 Ambulance/Inter-Hospital Transfer (Subject to prior approval)		N$2 480 per Family
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.	Specified Illness Conditions As per national guidelines for antiretroviral therapy (Sub-limits are pro-rated from the date of joining)	100%	N$42 600 per Family Overall Annual Limit
	17.1. HIV/AIDS (As per national guidelines for antiretroviral therapy)		N$ 25 100 per Beneficiary
	17.1.1. Medicine Paid at the maximum Namibia medicine price list on generics		Payable from Specified Illness Conditions
	17.1.2. First Full HIV Consultation/Assessment Once-off Benefit	N$480
	17.1.3. Consultation (after the first full HIV Consultation/Assessment) Six consultations per Beneficiary	N$440
	17.1.4. HIV Counselling	100%	N$1 300 per Beneficiary
	17.1.5. Pathology Tests (Subject to prior approval)	100%	N$5 650 per Beneficiary
	17.1.6. HIV Resistance Test (Subject to prior approval)	100%	Payable from Specified Illness Conditions
	17.2. Prevention of Mother-to-Child Transmission (PMTCT) As per national guidelines
	17.3. Post-Exposure Prophylaxis (PEP) As per national guidelines
	17.4. Pre-Exposure Prophylaxis (PrEP) As per national guidelines

Category B: DAY-TO-DAY BENEFIT		COVER	Overall Sub-benefit limit N$18 550 Per Beneficiary N$25 100 Per Family Sub-limits are pro-rated from the date of joining, except the optical benefit. OVERALL ANNUAL LIMIT
18.	General Practitioners and Specialists (out-of-hospital, including casualties) GP Telephonic/Virtual Consultations (telephonic/virtual writing of prescriptions not payable) Seven virtual/telephonic consultations per Beneficiary		N$6 200 per Family
	18.1. Consultations/Visits	100%	Payable from General Practitioners and Specialists Benefit
	18.2 Procedures/Services (out-of-hospital, including casualties)
	18.3. Materials and Disposable Items (Out-of-Hospital)
	18.4. Radiology & Pathology (Out-of-hospital, including radiography, sonography, medical laboratory technology and chemical biochemistry) (A referral from a Medical Practitioner is required)
	18.5 MRI and CT Scan		Payable from the MRI and CT Scan Benefit
	Benefit Booster is Applicable (Additional benefit once limit is exceeded)
19.	Medicine and Injections	SEP + 40%	N$13 000 per Family
	19.1 Acute Medication/Injections Paid at the maximum Namibia medicine price list on generics	100%	N$6 500 per Family
	19.2 Essential Vaccination/Immunisation Paid at the maximum Namibia medicine price list on generics		Payable from the Medicine and Injections
	19.3 Self-Medication Paid at the maximum Namibia medicine price list on generics		N$860 per Family N$125 per claim per Beneficiary
20.	Primary Health Care Services	100%	N$1 000 per Family
	20.1. Consultations and Procedures		Payable from Primary Health Care Services
	20.2. Medicine and Injections Paid at the maximum Namibia medicine price list on generics		Payable from Medicine and Injections
	Benefit Booster is Applicable (Additional benefit once limit is exceeded)
21.	Dentistry	100%	N$4 500 per Family
	21.1. Conservative and Specialised Dentistry (Including Dental Therapy) Benefit Booster Applicable (Additional benefit once limit is exceeded)		Payable from Dentistry benefit
	21.2. Maxillo-Facial, Oral Surgery and Dental Implants		No Benefit
	21.4 Orthodontics		No Benefit
22.	Optical Every two years (including frame) (2023-2024)	100%	N$3 670 per Family
	22.1. Eye Tests, Spectacles and Contact Lenses		N$1 300 per Beneficiary every two years
	22.2. Frame		N$520 per Beneficiary
23.	Auxiliary Services (Supplementary Services)	100%	N$2 370 per Family
	23.1. Consultation and Procedure		Payable from Auxiliary Services
	23.2. Medicine		Payable from Medicine and Injections (Acute and Chronic)
	Benefit Booster is Applicable (Additional benefit once limit is exceeded)
24.	External Appliances (Subject to MHC Guidelines)	80% of Cost	N$ 2 600 per Family
25.	Wheelchair, Artificial Limbs, Artificial Eyes, Hearing Aid Apparatus, Devices for Diabetes Management		No Benefit
26.	Benefit Booster Applicable if Medicine and Injections, Dentistry, GPs and Specialists, Primary Health Care and Auxiliary Services benefits are depleted		N$1 200 per Family
	26.1. Medicine and Injections (Acute and Chronic) Excluding self-medication	70%	Payable from Benefit Booster
	26.2. Dentistry	70%
	26.3. General Practitioners and Specialists (Consultations/visits and procedures/services out-of-hospital, including casualties)	80%
	26.4. Primary Health Care	80%
	26.5. Auxiliary Services	70%

CATEGORY C: BACK-UP BENEFIT	COVER
CATEGORY C: BACK-UP BENEFIT	COVER	M	M1	M2	M3	M4	M5+
Threshold Limit		4 700	5 310	5 510	5 710	5 910	6 100
Back-Up Benefit: The Back-up benefit aims to reward members and their dependants with low claims on the following specified day-to-day benefits: 1. Medicine and Injections per family limit 2. Optical per family limit 3. Auxiliary Services per family limit Suppose the actual total amount paid by NMC per family on the day-to-day benefits stipulated above for the current benefit year is less than the threshold limit. In that case, the member qualifies for Back-Up Benefit the following year, such as on the 2025 benefit year. The Back-up benefit is calculated as 15% of the difference between the Threshold Limit and the actual total amount paid by NMC on the day-to-day benefits stipulated above. The Back-up benefit will only be calculated at the end of April 2025 to ensure that all day-to-day claims, as stipulated above for the current benefit year, are included. Claims against the Back-up benefit for the current benefit year will only be processed after the end of April 2025. The unused Back-up benefit can be accumulated and carried over to the following benefit year. If the member resigns from NMC, any Back-up benefit balance will go to the Fund reserves. If the member passes away and their dependants remain with NMC, the Back-up benefit will be transferred to the remaining dependants. The Back-up benefit can be used to pay the excess on the NAMAF Tariffs, member co-payments and rejected claims in terms of NMC rules. The Back-up benefit cannot be used to pay for claims rejected due to non-compliance with the NAMAF billing rules and guidelines.


EXAMPLE OF HOW THE BACK-UP BENEFIT WILL BE CALCULATED
	M	M1	M2	M3	M4	M5+
A. The total amount paid by NMC (at the end of April 2025 for 2024 claims) for the following family limits: Medicine and Injections Optical Auxiliary Services	3 800	4 250	9 850	15 200	18 700	4 700
B. Threshold Limit	4 700	5 310	5 510	5 710	5 910	6 100
C. Difference: Threshold Limit (B) - Total Paid Amount (A)	900	1 060	0	0	0	1 400
D. Back-up Benefit = 15% of C (Available from 01 May 2025)	135	159	Does not qualify because The Total Benefit Amount (A) is more than the Threshold Limit (B)			210

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Our Benefits - Options and Benefits | NMC

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