The National Health Insurance Scheme (NHIS) is a social health insurance programme designed by the Federal Government of Nigeria to complement sources of financing the health sector and to improve access to health care for the majority of Nigerians. The main objectives of the scheme as set out in Act 35 of 1999 are:
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.
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.
How the Scheme Works
1. Each employer wishing to participate in the scheme registers with the NHIS and is assigned with a registration number.
2. The employer selects an accredited HMO and supplies all the necessary personal details. The NHIS issue an ID card to the enrollee and their eligible dependant
3. The PCP takes care of all the primary health care issues of the enrollee based on the NHIS benefit. The PCP will refer the employee to a secondary or tertiary provider accredited by the NHIS for specialized cases, with the approval from the HMO, using the established referral guidelines as listed below in the referral section.
4. The HMO will pay the PCP a global capitation of the N550 per member per month, which has been pre agreed.
5. When the claim is presented, the HMO reimburses the specialist on the pre agreed fee-for- service tariff as prescribed by the NHIS. The appropriate referral must be made before payment is made.
6. Claims shall be submitted monthly by the 14th day of the month following the month in which the claims are incurred. The HMO will reimburse all clean claims within 14 days of receipt of the claim.
7. Standardized pharmacy prescription sheets shall be 3-4 ply for the distribution to the doctor, pharmacy and HMO for notification of claims.
The NHIS enrollees are entitled to the following benefits:
1. Out-patient care, including necessary consumables
2. Prescribed drugs, pharmaceutical care and diagnostic tests- as contained in the National Essential Drug List and Diagnostic Test List.
3. Maternity care for up to four (4) live births for every insured contributor/couple in the Formal Sector Programme.
4. Preventive care, including immunization as it applies to the National Programme on Immunization, health education, family planning, antenatal and post-natal care.
5. Consultation with specialist such as physicians, pediatricians, obstetricians, gynecologists, general surgeons, orthopedic surgeons, ear nose and throat (ENT) surgeons, dental surgeons, radiologists, psychiatrists, ophthalmologists, physiotherapists.
6. Hospital care in a standard ward for a stay limited to a cumulative 15 days per year in non military Hospitals and no limit in Military Hospitals. The primary provider shall pay per diem for the bed space for a total of 15 days cumulative per year. Thereafter, the beneficiary and/or the employer Pay.
7. Eye examination and care excluding provision of spectacles and contact lenses; a range of prostheses limited to artificial limbs produced in Nigeria.
8. Preventive dental care and pain relief including consultation, dental health education, amalgam filling, and simple extraction.
9. All providers are expected to provide counseling as an integral part of quality care.