HMO Harps On NHIS Enrollees Rights

The Medical Director,
United Healthcare, Dr Kolawole Owoka, has said that it was the responsibility of Health Maintenance Organisations (HMOs) to sensitise enrollees for the smooth running of health insurance programmes.
Speaking with journalists in Abuja  last Friday, Owoka said that most enrollees to health insurance programmes lacked basic knowledge of their rights.
“With the role involves prompt payment to providers, ensuring good quality of healthcare services and liaising with all stakeholders involved to facilitate the smooth running of the scheme,” he said.
The National Health Insurance Scheme (NHIS) programmes was designed to cover public sector, including employees of federal, state and local governments, uniformed services, organised private sector, students of tertiary institutions and voluntary participants.  Owoka,  benefit packages in the NHIS are out-patient care including necessary consumables, maternity care for about four live births for every insured contributor in the formal sector.
He said “preventive cares including immunisation as regards national programme on immunisation, health education and family planning education, general consultation, specialist consultation are parts of benefit packages. The benefit also covers hospital care in a standard ward for a stay limited to cumulative 15 days per year, eye examination and care, excluding the provision of spectacles and contact lenses.
“Also minor surgeries and major surgeries asides the ones on the exclusion list are benefit of the scheme to an enrollee,” Owoka said.
The managing director stated that NHIS enrollees were entitled to hospitalisation in general wards only with the exclusion of meals.
However, he said the use of amenities in private wards and feeding would attract extra charges to the enrollees at the point of use.
Despite benefit packages from the scheme, Owoka stated that there were health conditions totally and partially excluded from insurance programmes.
“Occupational, industrial injuries, injuries from natural disaster, conflicts, epidemics, injuries from extreme sports like car racing, horse racing, Polo, mountaineering, boxing and wrestling, among other injuries are not captured in insurance programmes”, he stated.
“Let me also say that treatments of drug abuse, terminal diseases, transplant and cosmetic surgeries, high cost surgical procedure, hearing aids and associated appliances, chronic renal failure, congenital abnormalities, infertility management were excluded in the NHIS services.
“Partial exclusions can be for life saving emergency treatment requiring high technology investigations.
“In that case, the HMO would pay 20 per cent of the cost of treatment while the other 80 per cent will be paid for by the contributor or employee,” Owoka said.
He noted that there were cases when enrollees would require referrals from a primary to an advanced healthcare provider, adding that there were procedures to achieve such.
According to him, a referral line should be established; there should be a clinical basis for referral, a referral letter to accompany every case.
Owoka stated further  that  personal, medical details of the patient should be contained in the referral letter, an investigation carried out at a lower level of healthcare before sending to a higher level.