An employer registers himself and his employees
with the scheme. Therefore, the employer affiliates himself with a NHIS
approved Health Maintenance organization ‘A’, who will thereafter provide the
employees/contributors with a list of NHIS approved Healthcare Providers (Public
and Private).
The employee registers himself/herself and dependant(s) with such
providers of his/her choice. Upon registration, a contributor/employee and
his/her dependant(s) will be issued identity cards with personal identification
numbers(pin). In the event of sickness, the contributors/employee 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 Healthcare Provider after a minimum period
of six(6) months, I f 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 Healthcare Provider. A contributor may however, be asked
to make a small co-payment (where applicable) at the point of service.
1.2.1.
Payment System:
Healthcare providers under this scheme
will either be paid by capitation, fee-for-service, per-diem or case payment.
· Capitation
This
is payment to a Primary Healthcare 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 irrespective of whether enrollees utilize
the service or not.
· Fee-for
service
The
HMO makes this payment to non-capitation receiving Healthcare Providers who
render services on referral from other approved providers.
· Per-Diem
Per-diem
fees are payments for services and expenses everyday (medical treatment, drugs,
consumables, admission fees, etc) during hospitalization.
· 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.
1.2.2. Arbitration
The
State Health Insurance Arbitration Boards in each state of the Federation and
the Federal Capital Territory shall consider complaints by aggrieved parties.
1.3.
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.
1.3.0.
Healthcare Benefits:
The participants, based on their health
needs, will choose the healthcare benefits.
1.3.1. Contributions:
Participants
will pay this as a flat rate monthly. The contribution rate will depend on the
health package chosen by members of the use group.
1.3.2.
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. Each component Association
is to be represented on the board.
1.3.3.
How the Programme Works:
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
use Group will elect its Board of Trustees (BOT) which will administer it and
set up Quality Assurance and Health Education Committees. Each contributor will
be given an identity card from the chosen Healthcare Provider (public or
private) after a specified waiting period.
1.4.0.
Rural Community Social Health Insurance Programme:
This is a non-profit health Insurance programme
for a cohesive group of households or individuals (ie a community) which is run
by its members. Membership comprises of individuals in the community.
1.4.1. Healthcare Benefits
Members
of the community, based on their health needs, will choose the health care
benefits.
1.4.2. Contributions:
This
will be in cash, paid as a flat rate monthly or instrumentally by participants.
This contribution will depend on the health package chosen by members of the user
Group.
1.4.3. Administration
A
seven-member Board of Trustees, elected from among the members ie Chairman, Secretary,
Treasurer and four others, will manage the funds and run the user Group formed.
1.4.4. How the Programme Works
A prospective participant
must be a member.........................................................
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