PRESENTATION ON DHML ENROLLEES/HEALTHCARE

PROVIDERS ENLIGHTENMENT

By

Arogundade Adekemi

INTRODUCTION

What is INSURANCE

What is HEALTH INSURANCE

National Health Insurance Scheme

(NHIS)This is a social health insurance programme established under Act 35 of 1999 by the Federal Government of Nigeria to complement sources of financing healthcare and to improve access to health care for all Nigerians.

SCOPEThis presentation will cover the following;The main objectives of NHIS Brief History of DHMLSource of fundingOperations of the schemeServices covered by the schemeServices excluded from the schemeConclusionQuestion & Answers

Objectives of NHIS To ensure that every Nigerian has access to good

health care services.

To protect families from the financial hardship of huge medical bills.

To limit the rise in the cost of health care services.

To ensure equitable distribution of health care cost among different income groups.

To improve and harness private sector participation in the provision of health care services.

To ensure adequate distribution of health facilities within the federation and equitable patronage of all levels of health care.

To ensure the availability of funds to the health sector for improved services.

DEFENCE HEALTH MAINTENANCE LIMITED (DHML)

The Defence Health Maintenance Limited is a corporate entity owned by the Ministry of Defence and the Nigerian Armed Forces as a health maintenance organization (HMO).

It was incorporated by corporate affairs commission (CAC) on the 21st October,2005;accredited by the NHIS on the 27th of June,2006 and commenced operations in Nov,2006.

Board of Directors

Honourable Minister of state for Defence (chairman)

Permanent secretary of MOD

The Chief of Defence staff (CDS)

Chief of Army staff (COAS)

Chief of Naval staff (CNS)

Chief of Air staff(CAS)

Managing director-DHML as the secretary to the board.

Technical Committee Head of Health Services-MOD

Director of Medical Admin & Logistics- DHQ

Corps Commander Medical-NA

Director of Medical services Nigerian Navy

Director of Medical services Nigerian Air force

MD-DHML.

DHML (Contd)

DHML currently has six (6) zonal offices ;

North-East

North-West

North-Central

South-West

South-East

South-South

DHML (Contd)

DHML is among the 76 HMOs accredited by NHIS. It currently operates about 155 Military primary healthcare providers and about 157 secondary/tertiary HCP ; of these 33 are Military health care facilities while 124 are civilian healthcare facilities spread across the Country .

OBJECTIVESVISIONMISSION

FUNDINGThe Federal Government of Nigeria pays the full Premium for all its Uniformed Officers, these include members of the Nigerian Armed Forces, the Nigerian Police, Nigerian Customs service, Immigration, Prisons and Civil Defence Corps Personnel and in addition the Retired Military Personnel.

“No deduction is made from the salaries of the above mentioned or from the pension of the retired military personnel“.

DHML is funded like any other HMO by NHIS only. It does not receive subvention from the Ministry of Defence or from the Services.

OPERATIONS OF THE SCHEME

Each employee wishing to participate in the scheme registers with NHIS and is assigned a registration number.

NHIS then issues an ID card to the enrollee and his eligible dependants which includes the spouse and 4 biological children below 18 years. The primary care provider (PCP) takes care of all the primary health care needs of the enrollee based on NHIS benefit package.

OPERATIONS OF THE SCHEME (contd)

The PCP could refer the enrollee to a secondary or tertiary healthcare provider accredited by the NHIS subject to the approval of the HMO.

The HMO pays the PCPs a pre-agreed global capitation of N750 monthly.

All claims for specialist treatment are presented to the HMO for verification and re-imbursement at a pre-agreed fee-for-service tariff as prescribed by the NHIS.

BENEFIT PACKAGEAll enrollees of the NHIS are entitled to the following benefits:

Out-patient care, including necessary consumables as in NHIS standard treatment guidelines and referral protocol.

Prescribed generic drugs, pharmaceutical care and diagnostic tests as contained in the National Essential Drug and diagnostic test lists.

Routine maternity care for ALL pregnancies (four (4) live births) for every insured contributor/couple in the formal sector.

Preventive care, including immunization as it applies to the National Programme on Immunization, health education, Child welfare services , ante-natal , post-natal care and family planning education.

BENEFIT PACKAGE (contd)

Consultation with specialist such as Physicians, Pediatricians, Obstetricians & Gynecologists, General surgeons, Orthopedic surgeons, Ear Nose and Throat (ENT) surgeons, Ophthalmologists etc.

Hospital care in a standard ward for a stay limited to a cumulative 21 days per year following referral.

Eye examination and care with low priced spectacles ,a range of prostheses limited to artificial limbs produced in Nigeria.

Preventive /Promotive oral care and pain relief including consultation and dental health education.

In cases of emergency the enrollee shall visit his PHCP or the nearest NHIS accredited health care facility. The facility is to offer emergency care where applicable before referral if necessary and notification of HMO must be within 48 hrs.

EXCLUSIONS

TOTAL EXCLUSIONS Operational Injuries.

Occupational/industrial injuries. These are covered under the workman compensation Act.

Injuries resulting from conflicts, social unrest, riots, wars and natural disasters e.g earthquakes flood or land slide.

Epidemics.

Family planning commodities including condoms.

Injuries arising from extreme sports e.g car racing, polo, boxing, wrestling etc.

Drug abuse/addiction

Domiciliary visits

EXCLUSIONS (contd)

Surgeries such as: Organ Transplant, cosmetic surgeries, open- heart surgeries, laminectomy and neurosurgery (except Borehole) etc

Ophthalmology- Provision of contact lens

Internal Medicine-Anti-tuberculosis drug, ARV’s.

ENT-Hearing aids and associated appliances

Paediatrics-Congenital abnormalities involving

major/extensive surgical repairs, e.g. TOF,ASD,VSD, separation of Siamese twins, omphalocoele, Hirschsprung disease etc.

Obstetrics & Gynaecology – Infertility Management.

EXCLUSIONS (contd)

Dental Care- Dentures, Crowns, Bridges, Bleaching and Implants.Terminal illnesses including all cancers.Pathology-Post-mortem examination

PARTIAL EXCLUSIONS

For the life saving emergency treatment requiring high technology investigations, the HMO would pay 10% of the cost and the other 90% paid for by the contributor/employer, e.g. CT Scan, MRI

CONCLUSION

Thank you for listening..