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.
- Out-patient care, including necessary consumables;
- Prescribed drugs, pharmaceutical care and diagnostic tests as contained in the National Essential Drugs List and Diagnostic Test Lists;
- Maternity care for up to four (4) live births for every insured contributor/couple in the Formal Sector Programme;
- Preventive care, including immunization, as it applies in the National Programme on Immunization, health education, family planning, antenatal and post-natal care;
- Consultation with specialists, such as physicians, pediatricians, obstetricians, gynaecologists, general surgeons, orthopaedic 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. 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.
- Eye examination and care, excluding the provision of spectacles and contact lenses;
- A range of prostheses (limited to artificial limbs produced in Nigeria); and
- Preventive dental care and pain relief (including consultation, dental health education, amalgam filling, and simple extraction).
A need for referral
A patient may be referred from a Primary to a Secondary Service Provider due to need for specialized investigations, for medical/surgical reasons or other services – diagnostic, physiotherapy etc, or from secondary to tertiary level.
Approval by the HMOs is necessary, except in emergencies where he cannot be reached and notification of such should be served within 48hrs.
Referrals should be to the nearest specialist as contained in the list of NHIS registered providers in the area.