WHO MAY BECOME MEMBERS OF THE SCHEME?

Full time employees and continuation members of Namdeb, De Beers Marine & NDTC and their dependents may if they so choose become members of the Scheme.

WHO CAN BE REGISTERED AS A DEPENDENT OF A MEMBER?

In terms of the Rules of the Scheme the following persons can be registered as dependents of a member:

• One spouse of a member legally married or married according to custom, who is not a member of another medical aid scheme, or do not have access to any other medical aid scheme;
• A life partner, means a person who shares a common household or common household expenses and is in a permanent relationship with the member for at least two years before the date of application to register as life partner. Such relationship to be confirmed by an affidavit from the member.
• Any minor child (including any stepchild or legally adopted child) of a member and the member’s spouse, who is not self-supporting;
• The child of member over the age of twenty one (21) who is a full time student at a registered institution until the maximum age of 25.
• A dependent as define above of a member who is due to mental or physical defects and who is not a member or a dependent of any other medical aid scheme.

WHEN SHOULD A MEMBER REGISTER HIS DEPENDANTS ON THE SCHEME

In terms of rules 7 of the scheme rule, A member with dependants must apply in writing within 30 days of the following dates for inclusion of dependants in his membership:

a) The date on which he applies for membership as a member if, on that date, he has dependants; or b) The date of his marriage, if such date occurs after he has become a member; c) The date of birth of any child/ren or the date of legal adoption, if children are born or legally adopted after the commencement of membership; or d) If application to include a dependant is made on a date later than that mentioned in rule 7.1 such application is subject to proof of insurability. e) Dependants registered at a date later than 4 months from the date of membership, if he/she prior to the date of application does not belong to any other medical scheme, will be excluded from cover for a certain period to a maximum of six months of pre-existing illness conditions subject to a medical report. f) An exclusion of existing illness conditions of 12 months shall be imposed on spouses and dependants of members opting not to cover them under the Namdeb Medical Aid Scheme at the first possible date and then joining later.

CAN I TERMINATE MY DEPENDANTS AND REJOIN THEM IN THE SAME YEAR AGAIN?

Dependants terminated from membership during a benefit year will only become eligible for re-registration in the beginning of the following benefit year starting 1 January subject to approval by the Board.

WHEN SHOULD A CLAIM BE SUBMITTED FOR PAYMENT?

In terms of the Scheme rules, all claims should be submitted within (4) four months from the date of treatment. Please note that it remains the core responsibility of the member to ensure that claims are submitted with in the four months claims period. Any claims submitted outside the claims period will not be paid by the Scheme and the member will be liable for payment of such claims directly to the health professional and or service provider.

WHAT IS HOSPITAL PRE-AUTHORIZATION

In terms of the Scheme rules, all in-hospital procedures must be pre-authorized prior to admittance. The purpose of pre-authorizations is to ensure that costs are monitored, and that membership and benefits are confirmed. Upon applying for authorization, members and the applicable health facility or health professional will be issued with a reference number and also be assisted with any queries regarding the condition or the procedure for which they are being hospitalized.

The preauthorization process is important , as it ensure that you as a member is well aware before the procedure or services is rendered what the Scheme will cover and whether there may be any co-payments . It also provide that confirmation that when you arrive at the health professional and or hospital on day of service or admission that you will not surprised with a request from the facility or doctor for cash payment or a large deposit.

IN WHICH CASES SHOULD I OBTAIN PRE-AUTHORIZATION?

Pre-Authorization should be obtained for the following cases:

• All in-hospital procedures and treatments.
• Out of Hospital Surgical Procedures
• MRI/CT Scan – In & Out of Hospital

CAN I ASK FOR A QUOTATION OR BREAKDOWN OF COSTS FROM MY DOCTOR BEFORE ANY SERVICES OR PROCEDURE?

Yes, and the scheme in fact encourages all members to obtain and submit quotations or cost breakdowns in order to obtain confirmation of what the Scheme will cover of the total cost. This will allow the member the opportunity to be informed in advance whether you will have any out-of-pocket expenses you will have to pay the health professionals. This will allow you to budget and make provision for the payment and even to ask the doctor or provider for a rebate or consider a second opinion and quotation for the procedure. The main reason why the scheme encourage members to obtain quotations, is primarily to empower members with information to enable them to make an informed decision and not to be surprised with large co-payments afterwards.

WHEN SHOULD THE PRE-AUTHORIZATION NUMBER BE OBTAINED?

• All pre-authorizations, except emergencies, should be obtained prior to admittance. In cases of emergencies pre-authorization can be obtained with-in 48 hours of admission.
• Authorizations numbers and confirmation form are issued to both the health professionals, health facility and the member.
• Any request for the costing of quotations for services can be done at any time

IF I OBTAINED A PRE-AUTHORIZATION NUMBER DOES IT MEAN THAT MY TREATMENT WILL BE COVERED IN FULL?

It is important to note that the main purpose of preauthorization is to confirm membership and authorize the treatment and provision in terms of the Namdeb Scheme benefit structures and the benchmark tariff that the Scheme use. For a member to confirm if the treating doctor or specialist cost will be covered, it is advisable to obtain a quotation on the treatment cost and submit it to the medical Scheme. And on the quotation the scheme will indicate the total amount that it will cover of the treatment.

WHAT SHOULD I DO AS MEMBER IF I DETECT AN INCORRECT CLAIM PROCESSED ON MY ACCOUNT?

• The medical aid scheme notifies members on claims payment via sms and statements emailed and posted.
• In this notification send to members, information regarding the total amount paid and the Provider to whom the payment was made are indicated.
• In an event where you as a member pick up after receiving the claims payment notification, that your or your registered beneficiary did not receive treatment as per indicated notification members are urged to contact the nearest Prosperity Health Client Service Office to report the matter.
• Prosperity Health will investigate the matter further.

TIPS TO MANAGE YOUR BENEFITS

• Ask whether your Healthcare Provider charge tariff or alternatively consider using a Healthcare Provider that charge the Benchmark tariff. It remains your choice and not prescriptive in any way or reflecting negatively on the doctor charging a higher fee.
• Obtain a quotation on planned treatments in advance and ensure that all Hospital Procedures are pre-authorized. You may submit the quote to the Administrator to check it against your available benefits and the Scheme Benchmark Tariff and that will point out, in advance whether your doctor charge a higher fee and that you will have to cover as a co-payment.
• Please note that although you may be required to submit a quote, pre-authorization only authorizes the procedure. Should the quote exceed the benefit or tariff offered by the Scheme the balance will be for your account?
• Visit your pharmacist or primary clinic for minor ailments such as flu, cuts and burns before seeing a doctor and buy OTC (over-the-counter medication). You will save a doctor’s consultation!
• Ask your doctor or pharmacist about the generic equivalent of your prescribed medication
• Register on the chronic program to prevent your chronic claims to be paid from the acute medication benefit. You will receive written confirmation of the registration and that will also reflect the medication registered. To save your benefits and reduce your co-payments it will also reflects the names generics alternatives. The letter is also send to your doctor and you may discuss it with him/her with your next consultation to consider changing to generics. Your doctor will know best!

GUIDE TO DOWNLOAD THE MOBILE APP

What is a Designated Service Provider (DSP)?

A designated service provider is defined as a health care provider or health facility who has reached an agreement with a medical scheme to provide selected treatment or services at a contracted Scheme rate. In terms of this agreement with a number of pharmacies in Windhoek and at the coast, have agreed to offer chronic medication to members at a lower mark-up and whereby members don’t have to pay a co-payment. Consult with Prosperity Health Managed Care Department for more information.

What is the Benefit of a DSP to a Member?

Should a member opt to receive any of their chronic medication (including HIV/Aids medication) and or any high cost medication from any of the DSP pharmacies, they will receive the following benefits:

• Buy medication at a lower mark-up and incur no co-payment
• Have access to the Pharmacists and be advised on generic equivalents resulting in your chronic benefits lasting longer. It stretches your available benefits!
• Your treatment will be closely monitored to ensure compliance with treatment prescribed and your medication will be delivered to you monthly and at an agreed date. Compliance and adherence to the correct use of your chronic medication is very important and should strictly be adhered to.
• Your chronic medicine will be delivered within the territory of Windhoek directly to the address of choice, and for members who reside outside Windhoek by Nampost Couriers. Nampost follows very strict quality control, cold chain delivery where necessary and implemented an electronic tracking op parcels to ensure prompt deliveries to almost 150 towns throughout Namibia.
• Nampost Couriers is already delivery high quality services to several healthcare professionals in Namibia with the collection and deliver of blood samples (laboratories) and high value and oncology medication to remote centers in Namibia.
• Members will receive a monthly sms reminder and phone call to inform you that your medication refill is due and that it will be delivered to you shortly.

Is it a Member’s choice to utilize the services of a Designated Service Provider?

• It is important to note that whilst offering the benefit to members, the Trustees are aware that members may have a long-standing relationship with a local pharmacy.
• The arrangement with the DSP pharmacies is primarily aimed to assist members to reduce their out-of-pocket payments and it is not compulsory and remain your choice whether you wish to participate it it. Or continue to obtain your chronic medication at your existing pharmacy and pay the co-payment
• The saving is only possible because the DSP Pharmacies are willing to provide the medication to members at a lower mark-up than the model used in Namibia.

How will the medicine be delivered for members who reside outside Windhoek?

• Members who reside outside Windhoek are advised to order their medication within 5- days before refill is due, and for members based in Windhoek, 3 days before refill to allow for delivery.
• The medicine will be properly packaged and distributed via Nampost Couriers overnight freight services. The medication will be addressed directly to members as the case currently with pharmacies delivering your medication and members will be required to show their Identification card and medical aid membership card upon collection.

What process should a member follow if they want to utilize the Designated Service Provider services?

• Members who wish to make use of the DSP services, should fax a copy of their chronic prescription to the following contact person:
  Ms. Geneva Vollmer
  Tel: 061 2999736
  Fax: 061 222161
  Email: This email address is being protected from spambots. You need JavaScript enabled to view it.
  NOTE: You may be required to complete a registration form to register your home or work delivery address
• Confirmation of receipt of processing of the prescription will be send to the member from the DSP pharmacies and the Pharmacy/pharmacists will remain in direct contact with members.