Click here to proceed.

1
(No Transcript)
2

• National Health Insurance Scheme (NHIS) Update.
  
• A
• Presentation to Nurses/Midwives
• At
• Premier Hotel Ibadan
• By
• Pharmacist Taiye Adeleye
• NHIS Zonal Coordinator South West Zone.
• 15th October, 2009.

3
PREAMBLE why health insurance?

• The need arises as a result of the fact that
• The existing health system is chaotic and
  inefficient.
• There is an increasing demand for more and better
  medical facilities as a result of increasing
  population and increasing awareness of the
  advantage of medical science.
• Members of the public are spending privately
  large sums of money on health.
• Health Insurance is thus simply put
• a mechanism of protecting people against high
  cost of health care by making prepayment prior to
  falling ill.
• It is a special social security arrangement in
  which everybody will be his brothers keeper and
• it goes a long way in showing the Governments
  determination to fulfill one of its social
  responsibilities.
• It also ensure that Health Care Providers will
  have ready-made patient pool and will be paid
  their capitation in advance while specialist
  Doctors will be paid on fee-for-service.

4
HealthCare Financing Definition

• Healthcare financing is the ways and means by
  which money is raised to fund health activities,
  as well as how it is used (that is the allocation
  of the funds).
• Financing agents Govt., Insurance Companies,
  NGOs, Employers, e.t.c.

5
FEATURES OF HEALTHCARE FINANCING - 1
6
SOCIAL HEALTH INSURANCE

• SPECIAL SOCIAL SECURITY ARRANGEMENT (BASED ON
  CONCEPT OF SOLIDARITY AND EQUITY) TO PROVIDE
  FINANCIAL PROTECTION TO PARTICIPANTS AGAINST ILL
  HEALTH.
• POOLING OF RESOURCES AND RISKS
• Mandatory Contributions
• Frees Up Some Govt. Budget.
• Resource Re-Allocation
• Financing Poverty Reduction Interventions
  (Pro-Poor)
• CONTRIBUTION BASED ON ABILITY
• ENJOYMENT OF SERVICE BASED ON NEED
• REGULATED BENEFIT PACKAGE BASED ON EQUITY

7
THE NATIONAL HEALTH INSURANCE SCHEME (NHIS) is
a body corporate with perpetual succession
established under Act 35, 1999, to provide social
health insurance in Nigeria where health care
services of contributors are paid from the common
pool of funds contributed by the participants of
the Scheme.
8
NHIS VISION
A strong, dynamic, and responsive Govt.
Parastatal (Agency) that is totally committed to
securing universal coverage and access to
adequate and affordable healthcare in order to
improve the health status of Nigerians,
especially for those participating in the various
programs/products of the Scheme
9
NHIS MISSION
To facilitate fair-financing of healthcare costs
through pooling and judicious utilization of
financial resources to provide financial risk
protections and cost-burden-sharing for people,
against high cost of health care, through various
prepayment(s) programs/products, prior to their
falling ill..in addition to providing
regulatory oversight on HMOs and HCPs
10
CORE NHIS FUNCTIONS

• Regulate Health Insurance practice
• Promote and develop Health Insurance Schemes
• Set standards for providers and HMOs
• Ensure quality of Health Care Service
• Mobilize additional Resources (domestic and
  external)
• Define Benefit packages for Health Insurance
  Operators
• Etc.

11
OPERATIONAL MODALITIES (1)

• ONLY PUBLIC AND ORGANIZED PRIVATE SECTOR
  EMPLOYEES AND EMPLOYERS WILL MAKE COMPULSORY
  CONTRIBUTIONS TO THE SCHEME
• PARTICIPATION BY SELF-EMPLOYED VOLUNTARY.
• MANDATORY CONTRIBUTION 10 AND 5 OF STAFF BASIC
  SALARY BY EMPLOYERS AND EMPLOYEES RESPECTIVELY
  EXCEPT FOR ARMED FORCES FOR WHICH GOVERNMENT IS
  TO CONTRIBUTE ALL THE 15.
• 10 vs. 15 (5 Deficit?)
• Govt. Subsidy?
• COMPREHENSIVE BENEFIT PACKAGE WITH SOME
  EXCEPTIONS AVAILABLE FOR THE EMPLOYEE, THE SPOUSE
  AND FOUR CHILDREN UNDER THE AGE OF 18.

12
NHIS Service Provision Benefit Package (1)

• Out patient care including necessary consumables
• Prescribed drugs, pharmaceutical care and
  diagnostic tests as contained in the NHIS
  Essential Drug List and Diagnostic Test Lists.
• Maternity care for up to four live births for
  every insured person under the Formal Sector
  Programme.
• Preventive care, including immunization as it
  applies in the National Programme on
  Immunization, health education, family planning,
  antenatal and postnatal care.

13
NHIS Service Provision Benefit Package (2)

• Consultation with specialists such as Physicians,
  Pediatricians, Obstetricians,
• Gynecologists, General Surgeons, Orthopedics
  Surgeons, ENT Surgeons, Dental Surgeons,
• Radiologists, Psychiatrists, Ophthalmologists,
  Physiotherapists etc.
• Hospital care in a standard ward for a stay
  limited to cumulative 15 days per year.
• Eye examination and care, excluding provision of
  spectacles and contact lenses.
• A range of prostheses (limited to artificial
  limbs produced in Nigeria).
• Preventive Dental care and pain relief (including
  consultation, Dental health education)

14
Full 15 NHIS Service Provision Benefit Package
(3)

• Prostatectomy (Full Coverage)
• Open reductions (Full Coverage)
• Life Saving emergencies requiring high technology
  investigation The Scheme will pay for 20
• Screening PSA, Pap smears, mammogram The Scheme
  would pay 20.
• Amalgam filing, extraction for relieve of pain
  (Full coverage)

15
EXCLUSIONS

• Occupation/Industrial Injuries
• High Technology Investigations e.g. CT Scan, MIR
• Injuries from Natural disasters, earth quakes,
  wars, Social unrest
• Epidemics
• Extreme Sports
• Drug abuse/addiction
• Major congenital anomalies/defects

16

• Transplants and Cosmetic Surgeries
• High cost Surgical procedures - Open heart etc
• Hearing aids, Spectacles and contact lenses
• Terminal illnesses, including all cancers
• Management of CVA
• Tuberculosis
• Infertility Management etc.
• Periodic Medical check-up unrelated to illness

17
REFERRALS Definition

• Sending a patient for a range of specialized
  investigations or care through the recognized
  three level of service primary, secondary and
  tertiary.

18
REFERRALS Procedures

• A referral line shall be established
• There shall be a clinical bases for referrals
• A referral letter shall accompany every case
• Personal and Medical details shall be contained
  in the referral letter
• Primary Provider shall seek pre-authorization
  from the HMO before sending a case to secondary
  level
• In the event of emergencies, pre-authorization
  should be obtained not later than 48 hr after
  presentation/resuscitation.
• All investigation carried out at lower level
  shall be sent to the higher level
• Referral cases shall be sent back to the
  referring Provider at the lower level with a
  medical report and instruction for follow-up
  management.

19
Monthly Report To HMOs

• All Primary Provider shall at the end of every
  month submit an Encounter Information to all the
  HMOs patients seen. The information must
  include Name of patient, NHIS number, Presenting
  complains, Diagnosis, treatment, Admission days
  (if applicable), Doctors remark, signature of
  enrolee
• Fee for service claims (for secondary providers)
  containing Name NHIS No of patient, Name
  NHIS No of patients Primary Provider, Name
  NHIS No of Secondary Provider, Complaints,
  Diagnosis, treatment given, Date of treatment,
  Amount Billed, Co-payment received (when
  applicable)
• Copy of Prescription or referral form from
  Primary Provider should be attached to claim form

20
Phased implementation strategy

• Government employees Public sector workers,
  Military, Para-military, Police, State and
  National Assembly Members, etc.
• Employees of large firms Manufacturing, Oil and
  Gas, Construction, Commerce, Financial
  institutions, etc.
• Employees of Small and Medium enterprises (SMES).
• Informal sector (e.g. Mechanics, taxi drivers,
  market men and women, etc).
• Communities, rural and urban dwellers.
• Vulnerable groups and others Prisoners,
  Permanently disabled, Aged/Pensioners, Children
  under 5 and pregnant women.

21
FUNDING OF THE SCHEME

• Funding for now is solely from contribution by
  the Federal Government of 10 of the Basic Salary
  (BS) of its workers in the main stream civil
  service.
• Funds are pooled and utilised in the operation of
  the Scheme.

22

• TRANSFER OF FUNDS FROM N.H.I.S. TO HMO
• CONTRIBUTIONS (GOVT. PUBLIC SECTOR)
• NHIS
• RESERVE FUNDS HMO
  NHIS (ADMIN COST)
• (Security Fund) for
• equalization
• CAPITATION (GLOBAL)
  FEE-FOR-SERVICE
• To Primary Providers To Secondary Providers
  To Tertiary Providers E.G, Specialists
  Hospitals
• Pharmacies
• Dentistry
• Laboratories
• Physiotherapy centre

23
Apportionment of funds

• Determined Actuarially.
• Breakdown as follow -

24
PAYMENT TO HEALTHCARE PROVIDERS

• Payment to Primary Healthcare Providers is by
  Capitation. .
• Payment is on monthly basis and 14 days in
  advance before due date (beginning of each
  month).
• The Secondary and tertiary providers are paid
  through negotiated Fee for Service on completion
  of service and presentation of bills.

25
PAYMENT TO HEALTHCARE PROVIDERS (Contd)

• The Primary Healthcare Provider shall be paid N
  550 (per registered beneficiaries) as capitation.
• The payment shall cover services in the benefit
  package for primary healthcare as contained in
  the NHIS Operational Guidelines, which shall
  include
• Consultation
• Emergency
• Drugs including injections (based on the Federal
  Government Essential drug -generic - list as
  contained in the NHIS price list).

26
PAYMENT TO HEALTHCARE PROVIDERS (Contd)

• Services offered by secondary/tertiary Healthcare
  providers are on referral basis.
• Except for the bed space to be paid on per-diem
  basis by the primary healthcare provider for
  cumulative 15 days per annum for each
  beneficiary, payments for investigations and
  drugs shall be paid through fee for service on
  presentation of bills to the HMOs.
• In the event, the hospital stay exceeds 15 days
  per annum the beneficiary or his employer shall
  pay for the bed occupancy.

27
PAYMENT TO HEALTHCARE PROVIDERS (Contd)

• Laboratory test
• Hospital stay( payment of bed space as per-diem
  to a secondary provider) for a total of 15days
  per annum.
• X-ray
• Minor Surgery
• Eye treatment
• Dental Treatment
• Pregnancy (2nd , 3rd and 4th deliveries)

28
PAYMENT TO HEALTHCARE PROVIDERS (Contd)

• Prescriptions for drugs are to be dispensed
  (filled) only by NHIS Accredited Pharmacies. The
  beneficiary pays a co-payment of 10 of the total
  cost of the prescription and the balance 90 is
  paid by the primary provider on presentation of
  bills by the Pharmacy.
• For laboratory services (NHIS accredited
  laboratories), no co-payment is paid by the
  beneficiary.
• Note Total cost is to be paid by the primary
  provider.

29
PAYMENT TO HEALTHCARE PROVIDERS (Contd)

• Services provided at secondary/tertiary care are
  paid for on fee for service basis by the HMOs.
• A co-payment of 10 on all prescribed drugs shall
  be paid by the beneficiary to the accredited
  Pharmacy. Balance of 90 of the cost shall be
  borne by the HMO.
• Consultation and investigations shall be paid by
  the HMO on presentation of bills.
• Other service fees e.g. surgery, specialists
  interventions, are specified in the NHIS approved
  price list for professional services,
  investigations and drug (based on the Federal
  Government Essential (generic) drug list).

30

• PRIMARY HEALTHCARE PROVIDER TO SECONDARY
  HEALTHCARE PROVIDER
• Payment for bed space is by Per-Diem.
• Secondary Provider shall submit claims to the
  Primary Provider for the bed space occupied by
  the patients referred for hospitalization
• In case of dispute the original bill must be paid
  while the dispute is subject to arbitration
  conducted by the HMO.

31
WORKING DOCUMENTS

• Operational Guidelines
• Standard Treatment Guidelines and Referral
  Protocol
• Drug price list
• Professional Service fees
• Laboratory Service fees
• Radiological fees

32

• Thank you for listening !!!