Benefits & Coverage
Claims & Procedures
Membership
Network & Service Providers
Payments & Contributions
Waiting Period
Product Categories
What types of medical aid plans does First Mutual Health offer?
First Mutual Health offers medical aid plans in two main categories:
Local Plans – Tlotlo
Local plans provide access to healthcare services within Botswana. Members can visit approved healthcare providers such as general practitioners, specialists, hospitals, pharmacies, and laboratories for covered services.
The local plans fall under the Tlotlo range, which has four tiers:
- Tlotlo Essential
- Tlotlo Standard
- Tlotlo Enhanced
- Tlotlo Premier
These plans are designed for members who travel infrequently and are content with cover primarily within Botswana. The premiums and benefits are in Botswana Pula currency.
International Plans – Express
International plans provide access to healthcare services both locally and outside Botswana. These plans allow members to receive treatment abroad, when necessary, subject to the Scheme rules and pre-authorization requirements.
The international plans fall under the Express range, which includes:
- Express Silver
- Express Gold
- Express Diamond
- Express Platinum
These plans are suitable for members who frequently travel outside their country of residence and require portable medical cover in addition to cover at home. The premiums and benefits are in United States Dollars.
How do I know which product category is right for me?
The right plan depends on your healthcare needs, budget, and whether you require local or international medical cover. Our team can assist you in choosing the plan that best suits your needs.
Plans & Dependents
Can I upgrade or downgrade my plan?
Yes, members can adjust their plans during renewal periods. Members may make one plan adjustment per year.
How do I add a dependent?
Submit the dependent’s details (ID, birth certificate, or marriage certificate) with a membership update form. The membership update form is downloadable from our website. For members who are part of a corporate account, the membership update form will need to be stamped by the corporate.
Emergencies
What should I do in case of an emergency?
Seek immediate medical care at the nearest health facility. Emergency admissions are allowable without pre-authorization particularly on weekends or public holidays, provided the health facility then seeks pre-authorization within 48 hours.
Is ambulance cover included?
All our plans include cover for ambulance services within Botswana, subject to preauthorization.
Contact Channels
How can I contact First Mutual Health?
Members can contact First Mutual Health through the following channels:
- Telephone: +267 316 4074
- Email: ClientServices@firstmutualhealth.co.bw
- Website: www.firstmutualhealth.co.bw
- Social media: FMH Botswana on X, LinkedIn and Facebook
- Office Location: Plot 54354, Second Floor, Central Business District, Gaborone
Benefits & Coverage
What services are covered?
Coverage includes hospitalization, consultations, prescribed medication, maternity care, pathology, radiology, dental, specialist care and emergency services.
Does the plan cover treatment outside Botswana?
Treatment outside Botswana requires pre-authorization on our local cards. Our service provider network across SADC, Kenya and India helps our International Card members to have hassle-free treatment while travelling.
Claims & Procedures
How do I submit a claim?
Claims are typically submitted to us electronically by health service providers. In cases where our members would have paid for services, claims for reimbursement can be submitted on our web portal or via email to claims@firstmutualhealth.co.bw. You’ll need receipts, medical reports, and proof of payment.
How long does it take to process a claim?
Claims are processed and paid within 15 to 30 days, depending on completeness of documentation.
Are pre-authorizations required?
Yes, for major procedures such as surgeries, hospital admissions, specialized treatments, or certain benefits like the optical benefit. Please check your Rule Book to see where you would require pre-authorization.
Pre – Existing Conditions
Are pre-existing conditions covered?
Pre-existing conditions are medical conditions that existed before joining the Scheme. Treatment related to these conditions may be subject to condition-specific waiting periods. Members must disclose all relevant medical history when applying for membership to ensure accurate underwriting and avoid claim disputes.
Membership & Eligibility
Who can join the medical aid scheme?
Any Botswana citizen or resident with a valid national ID or residence permit can apply for our local and international cards.
Any citizen or resident of Zimbabwe or Mozambique can apply for our international cards.
Dependents such as spouses, children, and legally recognized dependents may also be covered.
Is there an age limit for joining?
Most plans accept members from birth up to 64 years. Children are usually covered up to 18 years (or 24 if studying full-time).
Can foreign nationals join?
Yes, expatriates with valid work permits are welcome to apply for membership.
When does my membership start?
Membership starts on the first day of the month for which premiums have been paid and in respect of which the Fund has approved your application. Premiums are payable from the first day of the month with no proration, even if the application is submitted later in the month. Benefits will be accessible from the commencement date, subject to any applicable waiting periods.
When does membership start for newborn babies?
For a newborn, membership benefits are considered to start from the first day of the month in which the baby is born (e.g., if the baby is born on 15 March, the membership is effective 1 March). Important: The baby must be registered within six weeks of birth.
- Payment for the baby’s cover starts on the first day of the following month and should include the premium of the month in which the baby was born.
- If the baby is not registered within six weeks, normal waiting periods will apply.
- If the baby requires medical care in the first 24 hours of life before membership registration, they may receive care under the mother’s benefit.
Can I cancel my membership?
Yes. Members may cancel their membership by providing one month’s written notice for the Scheme. Membership will terminate on the last day of the month of the notice. Any claims for services received after the termination date will not be covered.
Network & Service Providers
Which healthcare providers can I visit?
Members may consult qualified and licensed healthcare providers, including general practitioners, dentists, pharmacists, specialists and other accredited practitioners.
Do I have to use specific providers?
Members have the freedom to choose their healthcare providers, provided the provider is properly qualified and licensed. However, provider fees should remain within reasonable and fair market rates.
Can I consult a specialist directly?
Members are encouraged to consult a General Practitioner (GP) first. If a specialist is consulted without a GP referral, the Scheme may limit the benefit to the amount that would normally be paid for a GP consultation.
Payments & Contributions
How much are monthly premiums?
Premiums, or contributions, vary depending on the plan type, family size, and level of cover.
How do I make payments?
Payments can be made via bank transfer. Members on the local card pay exclusively in Botswana Pula. Members on the international card pay exclusively in United States dollars.
What happens if I miss a payment?
Coverage may be suspended until arrears are settled. Continuous non-payment can lead to cancellation.
Co-Payment (Shortfall)
What is a co-payment or shortfall?
A co-payment (or shortfall) is the portion of the medical bill that the member must pay if the Scheme does not cover the full cost of treatment.
When would I need to pay a co-payment?
Co-payments may arise when:
- The healthcare provider charges more than the Scheme’s reimbursement rates.
- Your annual benefit limits or sub-limits have been exhausted.
Can co-payments ever be reduced or waived?
In certain cases, the Scheme at its discretion may review and adjust benefits through:
- Approval from the Adjudication Committee (Refer to rule book)
Waiting Period
What is a waiting period?
A waiting period is a specified period from the start of your membership during which certain benefits cannot be claimed. Waiting periods apply to new members, dependents being added, or members upgrading their plans.
What waiting periods apply when I join the scheme?
Waiting periods depend on whether you join as an individual member or through a corporate account.
Corporate accounts
- General waiting period: up to 3 months
- Maternity benefit: 9 months
- Optical and foreign specialist treatment: 10 months
- Certain treatments such as prosthetics, haemodialysis and chemotherapy: up to 18 months
Individual accounts
- General waiting period: up to 36 months
- Maternity benefit: 9 months
- Optical and foreign specialist treatment: 1 year
- Certain treatments such as prosthetics, haemodialysis and chemotherapy: up to 2 years
Are waiting periods always applied?
Not always. Waiting periods may be waived or reduced in certain situations, such as:
- If you join from another medical scheme within 3 months of leaving the previous scheme
- If approved by the Scheme’s Adjudication Committee
- If you join a large corporate group where waiting periods are waived under the Scheme rules.
Do newborn babies have waiting periods?
No. If a newborn baby is registered within six weeks of birth, waiting periods do not apply for those services which the mother has no waiting periods on.
Do waiting periods apply when upgrading my plan?
Yes. Upgrading to a higher plan may attract a four-month waiting period, during which you continue to access benefits under your previous plan.
Do waiting periods apply to pre-existing medical conditions?
Yes. If a medical condition existed before joining the Scheme, a condition-specific waiting period of up to 24 months may apply for treatment related to that condition. This means that treatment for that specific condition may not be covered during the waiting period.
Do corporate members have the same waiting periods as individual members?
No. Waiting periods may differ depending on the size of the corporate group.
For example:
- 10–49 principal members: Immediate access to primary healthcare services such as GP consultations, radiology, pathology, and prescription drugs.
- 50 or more principal members: The Scheme may waive general waiting periods and some condition-specific waiting periods, subject to the Scheme rules.