The Formal Sector Social Health Insurance Programme

ORGANIZED PRIVATE SECTOR HEALTH INSURANCE (OPS)

Definition:

A social health security system in which the healthcare of employees in the Organised Private Sector (OPS) is paid for from funds created by pooling the contributions of employees and employers.

Membership:

Employees of any Organized Private Sector organizations with five (5) staff or above are eligible to participate in the programme.

Contribution:

Under the OPS, the employer/employee pay 10%/5% of the employee’s basic salary respectively. However, the employer may decide to pay the entire contribution on behalf of the employee.

The 15% basic salary for 12 months gives the annual premium for the company. The company must pay this amount for their staff to benefit from the package. Renewal must be done at least two months to expiry of initial payment.

Scope of the Coverage

Contributions paid cover healthcare benefits for the employee, his/her spouse and four (4) biological children under the age of 18. More dependents or a child above the age of 18 can be covered on the payment of additional contribution by the principal as determined by the NHIS. Principals are entitled to register four (4) biological children each; however a spouse or a child cannot be registered twice.

Registration

Every employer shall register with the NHIA. The employer shall forward the nominal payroll of all the staff to be enrolled with details of their monthly basic salary. Contribution payable is calculated by the NHIA. The organization shall select a Health Maintenance Organization (HMO) after contribution is paid.

Public Sector Programme

The Programme:

Public Sector Social Health Insurance Programme is a social health security system in which the healthcare of the employees in the formal sector is paid for from fund created by pooling the contributions of the employees and employers.

Membership:

The members of the Programme including contributing members from all Federal Ministries, Department and Agencies (MDAs).

Contribution:

The contributions are earning related from both employers and employees. It is currently 15% of the basic salary or 5% of consolidated salary. The employer pays 10% and employee 5% of basic salary or 3.5% from employer and 1.5% from employee consolidated salary.

These contributions entitle the contributor, a spouse, and four biological children under the age of 18 to health benefits as contain in the NHIA benefit package.

Classification of the Healthcare Services:

There are three levels of care under the Authority. The health care services are categorized as primary, secondary and tertiary levels of healthcare services.

How the Programme works:

• Prospect enrollee visits any of the NHIA offices for registration with relevant documents and choose a Primary Healthcare Provider.
• The Employer chooses the Health Maintenance Organisation (HMO) for the Organisation.
• After the waiting period of Ninety (90) days, Enrollee is issued an NHIA number/ID card and becomes eligible to access healthcare in the chosen Primary Healthcare Provider
• In the event of sickness, the Enrollee presents his/her ID to the chosen primary health care provider for treatment.
• Upon treatment, an enrollee is expected to pay 10% of the cost of drugs only to the Healthcare Facility or Pharmacy in the point of service.
• For the cases that involve referrals, the HMO gives an authorization code and later settles the bill based on NHIA tariffs.
• The enrollee is expected to pay 50% of the bill for some drugs/services that are of high-cost such as CT scan, MRI and others.
• The enrollee has the right to report any case of denial of access to health services by Healthcare Provider.
• The enrollee also has the right to update of personal data in the NHIA database.

GROUP INDIVIDUAL AND FAMILY HEALTH INSURANCE PROGRAMME (GIFSHIP)

The Group Individual and Family Social Health Insurance Programme (GIFSHIP) is a Health Insurance that is taken up and paid for by Individuals, Families and Groups such as adoption by philanthropist and other non- governmental bodies who are not covered by any of the NHIA programmes. It is an all-inclusive programme targeted at leaving no one behind.

Eligibility and Membership:

1. Small scale enterprises with less the 5 staff.
2. Non cohesive groups of persons, such as Associations, Unions and institutions outside the Organized Private Sector (OPS).

• Self-employed individuals, families and groups.

1. Retirees and retiree associations.
2. Diaspora groups.
3. Foreigners living in Nigeria.

SUB- CATEGORIES OF GIFSHIP

1. GIFSHIP-g (GENERAL)

This is for Individuals, Families or Groups not covered under any NHIA programme. The plans under this sub-category are:

Individual:

Coverage:  One to Three persons

Contribution: Forty-Five Thousand Naira (N45,000.00)

Family:

Coverage:  Four to Nine persons

Contribution: Sixty Thousand Naira – One Hundred and Thirty-Five Thousand Naira (N 60,000.00 – N 135,000.00)

Group:

Coverage: Ten persons and above

Contribution: One hundred and Fifty Thousand Naira (N150, 000.00 and above)

2. GIFSHIP-c (CONSTITUENCY)

This programme is financed by members of the National Assembly for their respective constituencies.

3. GIFSHIP-r (RETIREES )

The programme is for retirees. They are paid for by their respective organizations.

4. GIFSHIP -n (NYSC )

GIFSHIP-n is financed by the Federal Government of Nigeria to cover the mobilised and serving corps members during their service year. Under this programme, no waiting period and co-payments are made by the corps members.

GIFSHIP OPERATIONAL MODALITIES

1. Declaration of interest in writing or by physical appearance in any of the NHIA offices.
2. Enrolment and payment (with selection of Healthcare Facilities and HMOs) at any NHIA State Office.
3. Generation of the Enrollee Register and access to care after a waiting time of a minimum of 90 days (for GIFSHIP-g only)
4. Following access to care, there is waiting period of 6 months before access to surgery and high technological investigation for GIFSHIP-g and GIFSHIP-r beneficiaries.