IHMS/NHIS Social Health Insurance Program

The NHIS / IHMS Social Health Insurance Scheme is a public-private sector partnership designed to employ the managerial tools of HMOs to ensure that all Nigerians have access to quality and affordable healthcare services.

The NHIS

The NHIS is a corporate body 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.

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 Health Care Providers.

Structure of THE NHIS/IHMS programme

Major roles and responsibilities of key stakeholders

NHIS:

  1. Register HMOs and accrediting providers.
  2. Issue appropriate guidelines to maintain the viability of the scheme.
  3. Approve the format of contracts proposed by HMOs for all health care providers.
  4. Determine, after negotiation, capitation and other payments due to health care providers.
  5. Advise on the continuous improvement of the quality of services provided under the scheme through the guidelines issued by the standards committee established by the enabling law.

 

HMOs

  1. Collection of contributions
  2. Purchasing of services
  3. Effective claims processing
  4. Ensure quality assurance
  5. Manage demand & perform other utilization management functions to contain cost

 

PROVIDERS

  1. Provide services as agreed to in their contracts with HMOs
  2. Ensure that clients are satisfied.

 

SUBSCRIBERS/ENROLLEES

  1. Pay subscription, if applicable
  2. Select primary care providers
  3. Take actions that will enhance sustainability of the Scheme.

Services provided under the NHIS /IHMS social health insurance programme

  1. Out patient care including necessary consumables
  2. Prescribed drugs, pharmaceutical care and diagnostic tests as contained in the NHIS
  3. Essential Drug List and Diagnostic Test Lists.
  4. Maternity care for up to four live births for every insured person under the Formal Sector Programme.
  5. Preventive care, including immunization as it applies in the National Programme on Immunization, health education, family planning, antenatal and postnatal care.
  6. Consultation with specialists such as Physicians, Pediatricians, Obstetricians, Gynaecologists, General Surgeons, Orthopaedic Surgeons, ENT Surgeons, Dental Surgeons, Radiologists, Psychiatrists, Ophthalmologists, Physiotherapists etc
  7. Hospital care in a standard ward for a stay limited to cumulative 15 days per year
  8. Eye examination and care, excluding provision of spectacles and contact lenses.
  9. A range of prostheses (limited to artificial limbs produced in Nigeria).
  10. Preventive Dental care and pain relief (including consultation, Dental health education)

 

Operational modalities

  1. Only public and organized private sector employees and employers will make compulsory contributions to the scheme
  2. Participation by self-employed voluntary.
  3. Mandatory contribution of 10% and 5% of staff basic salary by employers and employees respectively except for armed forces for which government is to contribute the 15%.
  4. Comprehensive benefit package with some exceptions available for the employee, the spouse and four children under the age of 18.
  5. Contributions of two working spouses will cover both of them and not more than 4 dependants under age 18.  For other dependants, surcharge to be made.
  6. A waiting period exists before enjoying benefits.
  7. All covered members to go through a primary provider first and can only go to next level of care as a referred patient.
  8. Covered members choose providers and may change providers after a defined period.