TH INSURA

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THE NATIONAL HEALTH INSURANCE SCHEME

HANDBOOK
CONTENTS Page

1. Introduction 2

2. The Need for the Scheme 2

3. The Objectives of the Scheme 2

4. Classification of NHIS Programmes 2

5. Stakeholders in the NHIS 7

6. NHIS Offices 8

7. Additional Information 8
 National Health Insurance Scheme v. To maintain high standards of health care delivery services within the
Scheme
vi. To ensure efficiency in health care services
1. Introduction vii. To improve and harness private sector participation in the provision of
health care services
Health insurance is a social security system that guarantees the provision of needed viii. To ensure equitable distribution of health facilities within the Federation
health services to persons on the payment of token contributions at regular intervals. ix. To ensure appropriate patronage of all levels of health care
x. To ensure the availability of funds to the health sector for improved
The National Health Insurance Scheme (NHIS) is a body corporate established under services.
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
4. Classification of NHIS Programmes
Scheme’s benefits programmes as well sets the general rules and guidelines for the
operation of the Scheme.
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
2. The Need for the Scheme
different segments of society, and these are:

The establishment of the Scheme was informed by the following factors: i.Formal Sector Social Health Insurance Programme
ii.Urban Self-employed Social Health Insurance Programme
i. The general poor state of the nation’s health care services iii. Rural Community Social Health Insurance Programme
ii. The excessive dependence and pressure on government-provided health iv. Children Under-Five Social Health Insurance Programme
facilities v. Permanently Disabled Persons Social Health Insurance Programme
iii. Dwindling funding of health care in the face of rising costs vi. Prison Inmates Social Health Insurance Programme
iv. Poor integration of private health facilities in the nation’s health care vii. Tertiary Institutions and Voluntary Participants Social Health Insurance
delivery system Programme
viii. Armed Forces, Police and other Uniformed Services
3. The Objectives of the Scheme ix. Diaspora Family and Friends Programme
x. International Travel Health Insurance Programme.
i. To ensure that every Nigerian has access to good health care services
ii. To protect families from the financial hardship of huge medical bills
iii. To limit the rise in the cost of health care services
iv. To ensure equitable distribution of health care costs among different
income groups

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4.1 Formal Sector Social Health Insurance Programme 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.
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
The contributions of two working spouses cover the spouses and four (4) children for each
ten (10) or more employees.
of them.

4.1.1 Health Care Benefits 4.1.3 How the Programme Works

i. Out-patient care (including consumables) An employer registers itself and its employee with the Scheme. Thereafter, the employer
ii. Prescribed drugs as contained in the NHIS Essential Drugs List affiliates itself with an NHIS-approved Health Maintenance Organization (s), who now
iii. Diagnostic tests as contained in the NHIS Diagnostic Tests List provide(s) the employees with a list of NHIS-approved Health Care Providers (public and
iv. Antenatal care private). The employee registers itself and dependants with such Provider of his/her
v. Maternity care for up to four (4) live births for every insured person choice.
vi. Post natal care
vii. Routine immunization as contained in the National Programme on Upon registration, a contributor will be issued an identity card with a personal
Immunization identification number (PIN). In the event of sickness, the contributor presents his/her
viii. Family planning identity card to his/her chosen Primary Health Care Provider for treatment. The
ix. Consultations with a defined range of specialists e.g. physicians, surgeons, contributor will be able to access care after a waiting period of thirty (30) days. This
etc will enable the completion of all administrative processes.
x. Hospital care in a public or private hospital in a standard ward during a
stated duration of stay, for physical or mental disorders; A contributor has the right to change his/her Primary Health Care Provider after a
xi. Eye examination and care excluding prescription glasses/spectacles and minimum period of three (3) months, if he/she is not satisfied with the services being
contact lenses given.
xii. Dental care, i.e., pain relief and treatment
xiii. Prostheses, i.e., Nigerian-made simple artificial limbs. 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
4.1.2 Contributions a small co-payment (where applicable) at the point of service.

Contributions are earnings-related and currently represent 15% of basic salary. The 4.1.4 Payment System
employer will pay 10% while the employee will only contribute 5% of basic salary to Health Care Providers under this Scheme will either be paid by capitation or fee-for-
enjoy health benefits. service or per diem or case payment.

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 4.2.2 Contributions
a. Capitation Participants will pay this as a flat monthly rate. The contribution rate will depend
This is payment to a Primary Health Care Provider by the HMOs, on behalf of a on the health package chosen by members of the User Group.
contributor, for services rendered by the Provider. This payment is made regularly
in advance for services to be rendered.
4.2.3 Administration
b. Fee-for-Service A seven-member Board of Trustees, elected from among the members, i.e., Chairman,
The HMO makes this payment to non-capitation-receiving Health Care Providers who Secretary, Treasurer and four others, will manage the funds and run the User Group
render services on referral from other approved Providers. formed. Each component Association is to be represented on the Board.

c. Per Diem 4.2.4 How the Programme Works

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

4.1.5 Arbitration Each contributor will be given an identity card with which he/she will obtain health
The State Health Insurance Arbitration Boards in each state of the Federation and care from the chosen Health Care Provider (public or private) after a specified
the Federal Capital Territory shall consider complaints by aggrieved parties. waiting period.

4.2 Urban Self-Employed Social Health Insurance Programme 4.3 Rural Community Social Health Insurance Programme
This is a non-profit health insurance programme for a cohesive group of households
This is a non-profit health insurance programme covering groups of individuals with or individuals (i.e. a community) which is run by its members.
common economic activities run by their members.
Membership comprises individuals in the community.
Individuals who are members of socially cohesive groups, which are occupation-based,
are free to join the Programme. 4.3.1 Health Care Benefits
Members of the community, based on their health needs, will choose the health care
4.2.1 Health Care Benefits benefits.
The participants, based on their health needs, will choose the health care benefits.
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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.
4.3.3 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.
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.
4.4.2. Contributions
The contributions will be fully paid by the Federal Government.
4.4.3 Administration
The National Health Insurance Scheme, using public and private health facilities that
meet NHIS standards, will directly administer the Programme.
4.4.4 How The Programme Works
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.

Each contributor will be given an identity card with which he/she will obtain health 4.5.1 Health Care Benefits
care from the chosen Health Care Provider (public or private), after a specified The health care benefits cover common illnesses.
waiting period.
4.5.2. Contributions
4.4 Children Under-Five Social Health Insurance Programme The contribution will be fully paid by the Federal Government.

This programme is designed for children under the age of five years, nationwide. 4.5.3 Administration
The National Health Insurance Scheme, using private and public health facilities that
4.4.1 Health Care Benefits meet NHIS standards, will directly administer the Programme.

The children will benefit from a health care package covering common childhood 4.5.4 How The Programme Works
illnesses.
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 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.
4.6 Prison Inmates Social Health Insurance Programme
This Programme is designed for convicted persons in prisons and borstal homes
nationwide.
4.6.1 Health Care Benefits
The health care benefits cover common illnesses.
4.6.2. Contributions
The contributions will be fully paid by the Federal Government.
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.
c. Employers
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 employee’s 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.

4.6.3 Administration d. Other Contributors

The National Health Insurance Scheme, using private and public health facilities that Contributors making small, affordable regular payments in the Urban Self-
meet NHIS standards, will directly administer the Programme. employed and Rural Community Social Health Insurance Programmes are
guaranteed access to quality healthcare whenever they fall ill.
4.6.4 How the Programme Works
An inmate of a prison or borstal home will be issued an identity card, which will be e. Health Maintenance Organizations (HMOs)
presented to a designated Health Care Provider whenever he/she is ill. NHIS will be These are limited liability companies which may be formed by private or
responsible for paying the Health Care Provider for services rendered. public establishments or individuals for the sole purpose of participating in
the Scheme. They are registered by the Scheme to facilitate the provision
5. Stakeholders in the National Health Insurance Scheme 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 Their functions include the following:-
and guidelines, while protecting the rights and enforcing the obligations ƒ Receive/collect contributions from eligible employers and employees
of all stakeholders. ƒ Collection of contributions from voluntary contributors
ƒ Payment of Health Care Providers for services rendered
b. Employees
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 ƒ Maintenance of quality assurance in the delivery of healthcare benefits in ii. Secondary and Tertiary Health Care Providers (Fee-for-service
the Formal Sector Social Health Insurance Programme. providers)
These include:
Note: All HMOs must be insured with NHIS-approved insurance companies. • General hospitals (Out-patient and in-patient care for medical,
surgical, paediatric, obstetric gynaecological patients, etc)
f. Board Of Trustees (BOTs) • Specialist hospitals
Participants in the Urban Self-employed and the Rural Community Social • Pharmacies
Health Insurance Programmes, through their elected Boards of Trustees, • Laboratories
plan, run and manage their own health care, thereby engendering a sense • Dental Clinics
of ownership and true community participation. • Physiotherapy clinics
• Radiography, etc
g. Health Care Providers
A Health Care Provider as provided for in the NHIS Act, is a licensed Note: All Health Care Providers are required to take malpractice
government or private health care practitioner or facility, registered by the insurance (professional indemnity) with NHIS approved insurance
Scheme for the provision of prescribed health benefits to contributors and companies.
their dependants. Health Care Providers can either be Primary, Secondary,
or Tertiary.
h. Other Stakeholders
i. International Organizations and Collaborating Partners
i. Primary Health Care Providers Their role includes the provision of technical and financial support to
Primary Health Care Providers will serve as the first contact within ensure the successful implementation of the Scheme, especially among the
the health care system, and they include: urban self-employed, rural communities, permanently disabled persons,
• Private clinics/hospitals; children under-five tertiary institutions and voluntary contributors.
• Primary Health Care Centres;
• Nursing and Maternity homes; and
ii. Non-Governmental Organizations (NGOs)
• Out-patient departments of General Hospitals, Out-patient
These organizations will assist in the areas of sensitization and mass
departments of the Armed Forces, the Police and other
mobilization to ensure adequate participation.
uniformed services, University Medical Centres and Federal
Staff Clinics
iii. Community Leaders
They will assist in community mobilization and coordination.

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 iv. The Media Headquarters Office
The media will assist in sensitization, assist health providers to disseminate The Headquarters of the National Health Insurance Scheme is located at
knowledge of the Scheme and guarantee mass participation. Plot No. 347F, Custom Close, off Adetokunbo Ademola Crescent, Wuse II,
Abuja.
v. Banks
Banks’ responsibilities under the Scheme include: Zonal Offices:
a) Take custody of all the funds accruing to the HMOs affiliated to it; Kaduna: No. 2, Waziri Drive, off Alkali Road, Kaduna.
b) Ensure the safety of all funds for the operation of the programme; Enugu: 23, Umuoji Street, Independence Layout, Enugu.
c) Provide on request, by the NHIS, information on the accounts of an Lagos: Plot 314A, Akin Ogunlewe Street, off Ligali Ayorinde Street,
HMO with the knowledge of the HMO Victoria Island, Lagos.
d) Forward monthly statement of accounts of the HMOs on authorization Ilorin: Block B, Commercial Complex, Opposite Kwara Hotel, Ahmadu
by the HMOs to the NHIS. Bello Way, Ilorin.
Benin: No. 21, Liberty Road (Now Tony Anenih Avenue), GRA, Benin
vi. Insurance Companies City.
Insurance companies are to provide cover (malpractice and indemnity Ibadan: 15A, Paul Hendrickse Road (Tolulope Walls), New Bodija Estate,
insurance) for Health Maintenance Organizations (HMOs) in the Scheme. Ibadan.
Maiduguri: No. 3, Shehu Laminu Way, Main GRA, Maiduguri
vii. Insurance Brokers
To coordinate and ensure that HMOs and healthcare providers take up 7. Additional Information
indemnity insurance cover. NHIS accredited Insurance Brokers will
monitor and ensure compliance by accredited HMOs, healthcare providers
For further enquiries, please contact:
and the insurance companies.
Head, Public Enlightenment and Mobilization Unit,
ix. Professional bodies Office of the Executive Secretary
Professional bodies will assist in sensitization and mobilization of health National Health Insurance Scheme, Plot No. 347F, Custom Close, off
professionals, as well guarantee their participation. Adetokunbo Ademola Crescent, Wuse II, Abuja.

Telephone No: +234-9-4130027, 4130028

6. NHIS Offices: Fax No: +234-9-4130026
Web site: www.nhis.gov.ng