The Health Insurance Scheme 2

In the first part of this post, we highlighted the genesis of the program, the parties involved, the various services/products available under the scheme and the coverage. In this second post, the roles of all the parties involved, modus operandi for the scheme and the process for accessing the scheme for the end users and Healthcare Facility owners will be reviewed.

National Health Insurance Scheme (NHIS)

NHIS is a body set up by Decree 35, of 1999 (now Act 35) to operate as Public Private Partnership with the core responsibility of regulating the Health Insurance Sector just as National Insurance Commission (NAICOM) oversees the activities of other insurance businesses (Life, General and Travel) and to provide accessible, affordable and qualitative healthcare for all Nigerians. The key responsibilities as stated under the Act 35 are summarized below:

1.   The Scheme shall be responsible for issuing appropriate guidelines to maintain the viability of the Scheme [section 6(b)]

2.    The Scheme shall be responsible for advising on the continuous improvement of quality of services provided under the Scheme through guidelines issued by the Standard Committee established under section 45 of this Act [section 6(g)]

3.  The council shall have the power to set guidelines for effective co-operation with other organizations to promote the objectives of the Scheme [section 7(f)]

Health Maintenance Organization (HMO)

This is a private or public incorporated company duly registered under the Corporate Affairs Commission and authorized by the NHIS solely to manage the provision of health care services through Health Care Providers accredited by the Scheme. They serve as the link between the healthcare providers (hospitals) and the enrollees (end-users). Just like an underwriting company, the HMO collects premiums from enrollees or their employers (organizations, schools, associations, unions, etc.) develop contractual relationship with various healthcare facilities to provide service for their clients and in turn settle all accruing bills for medical treatment.

The arrangement between the HMO and HCF could be based on fee-for-service (payment will be made based on treatment made) or by capitation (part of the premium paid in advance to the HCFs to handle all primary treatments while secondary and tertiary treatments will be based on fee-for-service.

HMOs are categorized into 3 and are free to choice where and how to operate based on the company’s share capital namely:

• State: can only operate within the state where the office is located
• Regional: can only operate within the region and Abuja (FCT). They are however excluded from handling formal lives
• National: operates across the country

 Healthcare Service Providers (HCF)

This includes the primary, secondary and tertiary healthcare facilities (hospitals, health centers, general hospitals, etc.) that are licensed/accredited by relevant authorities including HNIS to provide services to the populace. Each facility is required to meet spelt out standards by NHIS and upon approval, the facility will be added to the list that enrollees can select from and assigned lives to. The HCFs are usually categorized as primary, secondary and tertiary health providers and care should be made to properly identify them as such.

Mode of paying for the services rendered can be by fee-for-service or capitation or a combination of both depending of the level of facility and services rendered and as agreed with the HMO

Enrollee/Beneficiary

A person who has enrolled (or have been enrolled) with NHIS (Civil Servants) or to the HMOs through their employers or individually and who has made an up to date with the payment of agreed premium is entitled to be covered under the scheme. The modus operandi is thus:

1. An enrollment form is filled by the principal beneficiary and stating/including other beneficiaries e.g. spouse and 4 biological children. Other members of the family can be added as dependents by making additional payment

2.   One HCF is picked from the list to be provided by the HMOs or NHIS (can be found on the website) except where the other beneficiaries are resident in another location. It is advisable to consider proximity in the choice of HCF in the event of emergencies. Your existing HCF can be added to the scheme subject to the provider securing necessary approval from NHIS.

3.   Existing illnesses must be declared from inception as the principle of Utmost Good Faith also applies. This is to avoid conflicts and ensure proper documentation

4.  Upon payment of agreed premium, which is made in advance, health card will be issued to the enrollees/beneficiaries which will be presented to the chosen HCF to access treatment. Note that each beneficiary will be issued with a separate health card and as such is not transferable.

5. All treatment outside the primary healthcare will however need the approval of the designated staff of the HMO for control purposes and reduce abuse. Referrals to other HCFs with better facilities and expertise will/can be made should the need arises. Once treated, the beneficiary/enrollee will be required to sign the bill to confirm the treatment while the signed bill will be forwarded to the HMO for payment. For government workers, 10% of the cost of drugs will however be borne by the enrollee.

6.  The beneficiary however has the right to change the HCF after 90 days if not satisfied with the service or other reasonable complaints. The HCF can be blacklisted and deleted from the scheme is the offense is serious.

7.   Complaint and change of HCF should be forwarded through the HMOs

The package can also be extended to schools and structured based on the need and level of the education. For example, NHIS has developed a product to cater for the health needs of tertiary school students tagged Tertiary Institution Social Health Insurance Program (TISHIP). The scheme operates in partnership with the health centers to provide all levels of healthcare with provision for referrals to higher facilities should the need arise. For other levels of school, the sickbay is involved. The depth of the arrangement and contract however depends on the contractual agreement between the school authority and the HMOs.

It is however worthy of mention that there are some conditions that are excluded from the benefits package of the scheme. NHIS or its agent(s) is not under any obligation to provide such service(s). Effort should be made to identify the exceptions before taking up the policy.

Benefits to the Employers:

•  Medical budget can be accurately determined every year while spurious medical bills emanating from abuse are eliminated.

•    Improve industrial relations between the employers and the employees which translate into more dedication to duty.

•    Employee productivity is enhanced as incidence of absenteeism is reduced to the minimum as health issues are resolved early and promptly

•   The problems of slashing and query of medical bill by management is completely eliminated.

•    Proximity of the hospitals/HCF reduces time and provides support in time of emergency.

•   Provision of adequate data on physicians and hospital of a specialist nature covering all types of surgery, psychiatry or counseling.

•  Availability of funds for other welfare packages for staff such as pensions, and home ownership scheme etc.

Benefits to the Employees:

•   Unhindered access to quality preventive and curative medical care from certified physicians.

•    Referral system that guarantees the best of services without additional cost.

•    Access to best health screening facilities that guarantees identification of medical problems at the early stages with adequate treatments.

•    The issue of requesting for loans for medical treatments is completely eliminated.

•   Guaranteed peace of mind and immediate treatment to family members even when out of town as this translates to a healthy and wealthy family

•    Cost is no longer a barrier to qualitative healthcare, reduce unbudgeted expenses, limited visits to quacks and limit to self-medication.

Conclusion

The Health Insurance Scheme was designed to right the wrong and redeem/strengthen our healthcare delivery system, change our perception and attitude to healthcare services, reduce the burden on the employers and employees alike, boost the economy of the healthcare sector, promote professionalism and support the growth of the economy at large. No matter the resources available, the human capital is the essential tool to drive the conversion process and economic growth. 

A healthy workforce is a healthy organization and a healthy nation which translate to a wealthy nation! Take a policy today!

For further information on the sign-up processes or advice on type of policy that will suite your organization, depth of coverage and premium payable, send a mail to info@emoyolgroup.com or info@bizadvisory.tk