TIONAL H NA E

TH INSURA AL

THE NATIONAL HEALTH INSURANCE SCHEME HANDBOOK

CH E S EME NC

CONTENTS 1. 2. 3. 4. 5. 6. 7. Introduction The Need for the Scheme The Objectives of the Scheme Classification of NHIS Programmes Stakeholders in the NHIS NHIS Offices Additional Information 2 2

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7 8 8

National Health Insurance Scheme

1. Introduction
Health insurance is a social security system that guarantees the provision of needed health services to persons on the payment of token contributions at regular intervals. The National Health Insurance Scheme (NHIS) is a body corporate established under Act 35 of 1999 by the Federal Government of Nigeria to improve the health of all Nigerians at an affordable cost. The NHIS Act is the statutory authority for the Schemes benefits programmes as well sets the general rules and guidelines for the operation of the Scheme.

v. vi. vii. viii. ix. x.

To maintain high standards of health care delivery services within the Scheme To ensure efficiency in health care services To improve and harness private sector participation in the provision of health care services To ensure equitable distribution of health facilities within the Federation To ensure appropriate patronage of all levels of health care To ensure the availability of funds to the health sector for improved services.

4.

Classification of NHIS Programmes

In order to ensure that every Nigerian has access to good health care services, the National Health Insurance Scheme has developed various programmes to cover different segments of society, and these are: Formal Sector Social Health Insurance Programme Urban Self-employed Social Health Insurance Programme Rural Community Social Health Insurance Programme Children Under-Five Social Health Insurance Programme Permanently Disabled Persons Social Health Insurance Programme Prison Inmates Social Health Insurance Programme Tertiary Institutions and Voluntary Participants Social Health Insurance Programme viii. Armed Forces, Police and other Uniformed Services ix. Diaspora Family and Friends Programme x. International Travel Health Insurance Programme. i. ii. iii. iv. v. vi. vii.

2.

The Need for the Scheme

The establishment of the Scheme was informed by the following factors: i. ii. iii. iv. The general poor state of the nations health care services The excessive dependence and pressure on government-provided health facilities Dwindling funding of health care in the face of rising costs Poor integration of private health facilities in the nations health care delivery system

3.

The Objectives of the Scheme

i. ii. iii. iv. To ensure that every Nigerian has access to good health care services To protect families from the financial hardship of huge medical bills To limit the rise in the cost of health care services To ensure equitable distribution of health care costs among different income groups

4.1

Formal Sector Social Health Insurance Programme

This programme covers employees of the formal sector, i.e., the public sector and the organized private sector. It is mandatory for every organization with ten (10) or more employees.

The contributions made by/for an insured person entitles himself or herself, a spouse and four (4) children under 18 years of age, to full health benefits. Extra contributions will be required for additional dependants. The contributions of two working spouses cover the spouses and four (4) children for each of them.

4.1.1

Health Care Benefits

i. ii. iii. iv. v. vi. vii. viii. ix. x. xi. xii. xiii. Out-patient care (including consumables) Prescribed drugs as contained in the NHIS Essential Drugs List Diagnostic tests as contained in the NHIS Diagnostic Tests List Antenatal care Maternity care for up to four (4) live births for every insured person Post natal care Routine immunization as contained in the National Programme on Immunization Family planning Consultations with a defined range of specialists e.g. physicians, surgeons, etc Hospital care in a public or private hospital in a standard ward during a stated duration of stay, for physical or mental disorders; Eye examination and care excluding prescription glasses/spectacles and contact lenses Dental care, i.e., pain relief and treatment Prostheses, i.e., Nigerian-made simple artificial limbs.

4.1.3

How the Programme Works

An employer registers itself and its employee with the Scheme. Thereafter, the employer affiliates itself with an NHIS-approved Health Maintenance Organization (s), who now provide(s) the employees with a list of NHIS-approved Health Care Providers (public and private). The employee registers itself and dependants with such Provider of his/her choice. Upon registration, a contributor will be issued an identity card with a personal identification number (PIN). In the event of sickness, the contributor presents his/her identity card to his/her chosen Primary Health Care Provider for treatment. The contributor will be able to access care after a waiting period of thirty (30) days. This will enable the completion of all administrative processes. A contributor has the right to change his/her Primary Health Care Provider after a minimum period of three (3) months, if he/she is not satisfied with the services being given. The Health Maintenance Organization (HMO) will make payment for services rendered to a contributor to the Health Care Provider. A contributor may, however, be asked to make a small co-payment (where applicable) at the point of service.

4.1.2

Contributions

Contributions are earnings-related and currently represent 15% of basic salary. The employer will pay 10% while the employee will only contribute 5% of basic salary to enjoy health benefits.

4.1.4

Health Care Providers under this Scheme will either be paid by capitation or fee-forservice or per diem or case payment. 3

Payment System

a.

This is payment to a Primary Health Care Provider by the HMOs, on behalf of a contributor, for services rendered by the Provider. This payment is made regularly in advance for services to be rendered. The HMO makes this payment to non-capitation-receiving Health Care Providers who render services on referral from other approved Providers.

Capitation

4.2.2

Contributions

Participants will pay this as a flat monthly rate. The contribution rate will depend on the health package chosen by members of the User Group.

4.2.3

b.

Fee-for-Service

A seven-member Board of Trustees, elected from among the members, i.e., Chairman, Secretary, Treasurer and four others, will manage the funds and run the User Group formed. Each component Association is to be represented on the Board.

Administration

c.

Per Diem

Per diem fees are payments for services and expenses per day (medical treatment, drugs, consumables, admission fees, etc.) during hospitalization.

4.2.4

How the Programme Works

d.

Case Payment

This method is based on a single case rather than on a treatment act. A Provider gets paid for every case handled till the end.

A prospective participant must be a member of an already existing Association. This Association, together with other Associations, come together to form a User Group. There must be a membership of at least 500 participants for each User Group to ensure adequate pooling of resources. The User Group will elect its Board of Trustees which will administer it and set up Quality Assurance and Health Education Committees. Each contributor will be given an identity card with which he/she will obtain health care from the chosen Health Care Provider (public or private) after a specified waiting period.

4.1.5

Arbitration

The State Health Insurance Arbitration Boards in each state of the Federation and the Federal Capital Territory shall consider complaints by aggrieved parties.

4.2

Urban Self-Employed Social Health Insurance Programme

This is a non-profit health insurance programme covering groups of individuals with common economic activities run by their members. Individuals who are members of socially cohesive groups, which are occupation-based, are free to join the Programme.

4.3

This is a non-profit health insurance programme for a cohesive group of households or individuals (i.e. a community) which is run by its members. Membership comprises individuals in the community.

Rural Community Social Health Insurance Programme

4.3.1

Health Care Benefits

4.2.1

Health Care Benefits

Members of the community, based on their health needs, will choose the health care benefits. 4

The participants, based on their health needs, will choose the health care benefits.

4.3.2. Contributions

This will be in cash, paid as a flat monthly rate or instalmentally by participants. This contribution rate will depend on the health package chosen by members of the User Group.

4.4.2. Contributions 4.4.3

The contributions will be fully paid by the Federal Government.

4.3.3

Administration

A seven-member Board of Trustees, elected from among the members, i.e., Chairman, Secretary, Treasurer and four others, will manage the funds and run the User Group formed.

The National Health Insurance Scheme, using public and private health facilities that meet NHIS standards, will directly administer the Programme.

Administration

4.4.4

How The Programme Works

4.3.4

How The Programme Works

A prospective participant must be a member of a community. The individuals of the community come together to form a User Group. There must be a membership of at least 500 participants for each User Group to ensure adequate pooling of resources. The User Group will elect its Board of Trustees which will administer it, and set up Quality Assurance and Health Education Committees. Each contributor will be given an identity card with which he/she will obtain health care from the chosen Health Care Provider (public or private), after a specified waiting period.

A child under the age five years will be registered and issued an identity card, which will be presented to a designated Health Care Provider whenever the child is ill. The NHIS will be responsible for paying the Health Care Provider for services rendered.

4.5

Permanently Disabled Persons Social Health Insurance Programme

This is a programme designed to provide health security for permanently disabled persons in the Nigerian society who, due to their disability, cannot engage in any economically productive activity.

4.5.1

Health Care Benefits

The health care benefits cover common illnesses.

4.5.2. Contributions 4.5.3

4.4

Children Under-Five Social Health Insurance Programme

This programme is designed for children under the age of five years, nationwide.

The contribution will be fully paid by the Federal Government.

4.4.1

Health Care Benefits

The children will benefit from a health care package covering common childhood illnesses.

The National Health Insurance Scheme, using private and public health facilities that meet NHIS standards, will directly administer the Programme.

Administration

4.5.4

How The Programme Works

5

A permanently disabled person will be registered and issued an identity card, which will be presented to a designated Health Care Provider whenever he/she is ill. The NHIS will be responsible for paying the Health Care Provider for services rendered.

These are the contributors in the Formal Sector Social Health Insurance Programme. Their contributions (5% of basic salary), paid regularly in advance will guarantee them and their dependants good quality healthcare whenever they fall ill.

4.6

This Programme is designed for convicted persons in prisons and borstal homes nationwide.

Prison Inmates Social Health Insurance Programme

c.

Employers

4.6.1

Health Care Benefits

The health care benefits cover common illnesses.

4.6.2. Contributions 4.6.3

The contributions will be fully paid by the Federal Government.

These are public or private sector organizations employing ten (10) or more persons, for whom they are required to pay contributions (i.e., 10% of an employees basic salary). In the Formal Sector Social Health Insurance Programme, employers are guaranteed good quality health care for their workers at cheaper rates and a resultant increase in productivity. In addition, employers with in-house health facilities will run them cheaper and make them earn income by registering them as Providers under the Scheme.

Administration

The National Health Insurance Scheme, using private and public health facilities that meet NHIS standards, will directly administer the Programme.

d.

Other Contributors

4.6.4

How the Programme Works

Contributors making small, affordable regular payments in the Urban Selfemployed and Rural Community Social Health Insurance Programmes are guaranteed access to quality healthcare whenever they fall ill.

An inmate of a prison or borstal home will be issued an identity card, which will be presented to a designated Health Care Provider whenever he/she is ill. NHIS will be responsible for paying the Health Care Provider for services rendered.

e.

Health Maintenance Organizations (HMOs)

5.

Stakeholders in the National Health Insurance Scheme

These are limited liability companies which may be formed by private or public establishments or individuals for the sole purpose of participating in the Scheme. They are registered by the Scheme to facilitate the provision of health care benefits to contributors in the Formal Sector Social Health Insurance Programme.

a.

Government

Government, through the National Health Insurance Scheme, sets standards and guidelines, while protecting the rights and enforcing the obligations of all stakeholders.

Their functions include the following:-

b.

Employees

Receive/collect contributions from eligible employers and employees Collection of contributions from voluntary contributors Payment of Health Care Providers for services rendered 6


Note: f.

Maintenance of quality assurance in the delivery of healthcare benefits in the Formal Sector Social Health Insurance Programme.

ii. Secondary and Tertiary Health Care Providers (Fee-for-service providers)

These include: General hospitals (Out-patient and in-patient care for medical, surgical, paediatric, obstetric gynaecological patients, etc) Specialist hospitals Pharmacies Laboratories Dental Clinics Physiotherapy clinics Radiography, etc

All HMOs must be insured with NHIS-approved insurance companies.

Participants in the Urban Self-employed and the Rural Community Social Health Insurance Programmes, through their elected Boards of Trustees, plan, run and manage their own health care, thereby engendering a sense of ownership and true community participation.

Board Of Trustees (BOTs)

g.

Health Care Providers

A Health Care Provider as provided for in the NHIS Act, is a licensed government or private health care practitioner or facility, registered by the Scheme for the provision of prescribed health benefits to contributors and their dependants. Health Care Providers can either be Primary, Secondary, or Tertiary.

Note:

All Health Care Providers are required to take malpractice insurance (professional indemnity) with NHIS approved insurance companies. Other Stakeholders i. International Organizations and Collaborating Partners

h.

i.

Primary Health Care Providers will serve as the first contact within the health care system, and they include: Private clinics/hospitals; Primary Health Care Centres; Nursing and Maternity homes; and Out-patient departments of General Hospitals, Out-patient departments of the Armed Forces, the Police and other uniformed services, University Medical Centres and Federal Staff Clinics

Primary Health Care Providers

Their role includes the provision of technical and financial support to ensure the successful implementation of the Scheme, especially among the urban self-employed, rural communities, permanently disabled persons, children under-five tertiary institutions and voluntary contributors.

ii.

Non-Governmental Organizations (NGOs)

These organizations will assist in the areas of sensitization and mass mobilization to ensure adequate participation.

iii.

They will assist in community mobilization and coordination.

Community Leaders

iv.

The Media

The media will assist in sensitization, assist health providers to disseminate knowledge of the Scheme and guarantee mass participation.

Headquarters Office

v.

Banks

The Headquarters of the National Health Insurance Scheme is located at Plot No. 347F, Custom Close, off Adetokunbo Ademola Crescent, Wuse II, Abuja.

Banks responsibilities under the Scheme include: a) Take custody of all the funds accruing to the HMOs affiliated to it; b) Ensure the safety of all funds for the operation of the programme; c) Provide on request, by the NHIS, information on the accounts of an HMO with the knowledge of the HMO d) Forward monthly statement of accounts of the HMOs on authorization by the HMOs to the NHIS.

Zonal Offices:
Kaduna: Enugu: Lagos: Ilorin: Benin: Ibadan: Maiduguri: No. 2, Waziri Drive, off Alkali Road, Kaduna. 23, Umuoji Street, Independence Layout, Enugu. Plot 314A, Akin Ogunlewe Street, off Ligali Ayorinde Street, Victoria Island, Lagos. Block B, Commercial Complex, Opposite Kwara Hotel, Ahmadu Bello Way, Ilorin. No. 21, Liberty Road (Now Tony Anenih Avenue), GRA, Benin City. 15A, Paul Hendrickse Road (Tolulope Walls), New Bodija Estate, Ibadan. No. 3, Shehu Laminu Way, Main GRA, Maiduguri

vi.

Insurance Companies

Insurance companies are to provide cover (malpractice and indemnity insurance) for Health Maintenance Organizations (HMOs) in the Scheme.

vii.

Insurance Brokers

To coordinate and ensure that HMOs and healthcare providers take up indemnity insurance cover. NHIS accredited Insurance Brokers will monitor and ensure compliance by accredited HMOs, healthcare providers and the insurance companies.

7.

Additional Information

For further enquiries, please contact: Head, Public Enlightenment and Mobilization Unit, Office of the Executive Secretary National Health Insurance Scheme, Plot No. 347F, Custom Close, off Adetokunbo Ademola Crescent, Wuse II, Abuja. Telephone No: +234-9-4130027, 4130028 Fax No: +234-9-4130026 Web site: www.nhis.gov.ng

ix.

Professional bodies

Professional bodies will assist in sensitization and mobilization of health professionals, as well guarantee their participation.

6.

NHIS Offices: