I. GUIDELINES FOR THE OPERATIONS OF THE FORMAL SECTOR SOCIAL HEALTH INSURANCE PROGRAMME
The Formal Sector Social Health Insurance Programme is a social health security system in which the health care of employees in the Formal Sector is paid for from funds created by pooling the contributions of employees and employers.
The Formal Sector consist of the following:
§ Public Sector
§ Organised Private Sector
§ Armed Forces, Police and Allied Services
§ Students of Tertiary Institutions and
§ Voluntary Contributors
GUIDELINE FOR PUBLIC SECTOR AND ORGANIZED PRIVATE SECTOR
Employees of the public and organized private sector employing ten (10) or more persons shall participate in the Programme.
Contributions are earnings-related. The employer pays 10% while the employee pays 5%, representing 15% of the employee’s basic salary. However, the employer may decide to pay the entire contribution. In accordance with the existing contractual agreement between employers and employees, especially in the organized private sector, an employer may undertake extra contributions for additional cover to the benefit package.
1.4 Waiting Period
There shall be a processing (waiting) period of sixty (60) days before a participant can access services.
1.5 Scope of Coverage
The contributions paid cover healthcare benefits for the employee, a spouse and four (4) biological children below the age of 18 years. More dependants or a child above the age of 18 would be covered on the payment of additional contributions from the principal beneficiary. However children above 18 years who are in tertiary institution will be covered under Tertiary Insurance Scheme.
1.6 Benefit Package
Healthcare providers under the Scheme shall provide the following benefit package to the contributors:
i) Out-patient care, including necessary consumables;
ii) Prescribed drugs, pharmaceutical care and diagnostic tests as contained in the National Essential Drugs List and Diagnostic Test Lists;
iii) Maternity care for up to four (4) live births for every insured contributor/couple in the Formal Sector Programme;
iv) Preventive care, including immunization, as it applies in the National Programme on Immunization, health education, family planning, antenatal and post-natal care;
v) Consultation with specialists, such as physicians, pediatricians, obstetricians, gynaecologists, general surgeons, orthopaedic surgeons, ENT surgeons, dental surgeons, radiologists, psychiatrists, ophthalmologists, physiotherapists, etc.;
vi) Hospital care in a standard ward for a stay limited to cumulative 15 days per year. Thereafter, the beneficiary and/or the employer pays. However the primary provider shall pay per diem for bed space for a total 15 days cumulative per year.
vii) Eye examination and care, excluding the provision of spectacles and contact lenses;
viii) A range of prostheses (limited to artificial limbs produced in Nigeria); and
ix) Preventive dental care and pain relief (including consultation, dental health education, amalgam filling, and simple extraction).
Note: All Providers are expected to provide counselling as an integral part of quality care.
1.7 Registration of Employers and Employees
(a) Every employer shall register with the NHIS, upon which a registration number shall be allotted to it by the Scheme.
(b) Every employer shall appoint an NHIS-registered Health Maintenance Organisation (HMO) of their choice.
(c) Every registered employer shall supply the following information to the Scheme and to the appointed HMO:
(i) Name of employer,
(ii) Category of employer (public or private),
(iii) Management structure of the organization, and
(iv) Staff lists, including basic salaries.
(d) The employee shall register self, a spouse and four (4) biological children below the age of eighteen (18) years with the Scheme.
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