Psemas private hospitalisation cap raises ‘major concern’

Members of the government’s medical aid fund have had unlimited hospitalisation benefits at state hospitals since 1 April, while cover for private hospital admissions is capped at N$350 000 per beneficiary and N$700 000 per family.

Under the higher option for private care for Public Service Medical Aid Scheme (Psemas) members, these limits apply to accommodation, theatre costs, intensive and high care, medication, rehabilitation, hospice care and admission to mental health units.

Limited benefits also apply under the standard option, where private hospitalisation is covered only if a procedure cannot be performed in a state facility. If it is available in the public sector, payment is made in line with state tariffs.

The new benefit structures were introduced this month alongside Vision April 2026, which requires civil servants to use public health facilities as part of efforts to strengthen the system.

According to a well-placed source in the medical aid industry, the N$350 000 private hospital limit is insufficient to cover major procedures.

“This is a major concern for us. People are now cancelling their gap cover because they think they are fully covered. We have already had several cases of Psemas members who exceeded their N$350 000 limit,” the source said.

Gap cover in Namibia is an insurance product that covers the shortfall between medical aid tariffs and the higher fees charged by private doctors and specialists, helping to reduce out-of-pocket costs for hospital procedures.

It typically covers specialist fees in hospital, co-payments and, in some cases, specific out-of-hospital treatments or oncology expenses.

“I think the biggest change with the N$350 000 cap is that once you reach it and Psemas starts paying state tariffs, we cover the difference between the state and Psemas tariffs," the source explained.

Referrals, emergencies, benefits

Restrictions have also been placed on ambulance and evacuation services.

Approval is required for ambulance transport between hospitals or for non-emergency cases, with a limit of N$10 000 per beneficiary.

MRI and CT scans, both inside and outside the hospital, are capped at N$30 000 per family and require a referral from a medical specialist.

Referral from a general practitioner for CT scans in an emergency is justified only for head injuries.

For radiology and pathology, as well as blood transfusion services performed at a state hospital, the Psemas benefit remains unlimited.

Consultations with general practitioners and specialists outside the hospital are limited to N$7 000 for the principal member and N$16 000 for a principal member with four dependants.

Acute medication is limited to N$7 000 per member, while chronic medication ranges from N$15 000 for the principal member to N$35 000 for a principal member with four dependants.

Limits also apply to basic dentistry at N$10 000 per member. A once-off amount of N$16 500 per member is available for orthodontic treatment, subject to prior approval.

Eye tests are limited to one test per member every six months, while spectacles and contact lenses are limited to N$3 000 every two years. For frames, a Psemas member receives N$600 every two years.

Limits set

Members also have access to medical support devices such as wheelchairs (N$10 000 per member every four years), prosthetic limbs (N$30 000 per member), and orthopaedic shoes (N$1 860 to N$3 750), while hearing aid benefits amount to N$9 000 per ear per member annually.

Prior approval must be obtained for medical travel abroad, with the cost of an economy-class air ticket or bus ticket fully covered.

HIV and Aids medication is limited to N$35 000 per member, including pathology, and is subject to registration on the clinical monitoring programme for HIV/Aids.

According to an official circular by the justice ministry's executive director, Audrin Mathe, all government staff were required to complete and submit new Psemas application forms by 15 April.

The letter, dated 1 April, said this was necessary to align members’ records with the revised Psemas benefit structure and to avoid delays in accessing benefits.

Questions sent by Namibian Sun’s sister publication Republikein to finance ministry spokesperson Wilson Shikoto two weeks ago went unanswered.

These included whether retired civil servants are also required to re-register, and what the consequences would be for those who fail to submit forms by 15 April.