Introduction to Enrolee's Benefits Packages
The benefit package refers to the services provided by Healthcare Facilities in the scheme to the enrolees duly registered under them. These services are provided at three (3) levels of care; Primary, Secondary and Tertiary levels of care through an established referral system.
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Enrolee benefits packages
Enrolees registered with the scheme are entitled to these:
- Out-patient care with standard treatment
- Maternal care (Antenatal, delivery and Postnatal care)
- Pharmaceutical care
- Diagnostic test
- Specialist consultation
- Eye care
- Dental care
- Physiotherapy
- Annual medical checkup
- Minor and major surgeries
- Promotive and preventive care, immunization, health and family planning education
Services Provided
1. Out-patient care, including necessary consumables.
2. Pharmaceutical care as contained in the BHIS drug list.
3. Diagnostic test as contained in the BHIS diagnostic test list.
4. Maternal (Antenatal, Delivery and Postnatal) care for four (4) pregnancies ending in live birth.
5. All live birth eligible for cover will be covered during the postnatal period of twelve (12) weeks from the date of delivery for the formal sector programme.
6. All preterm/premature babies eligible to cover shall be covered for twelve (12) weeks from the date of delivery for the formal sector programme.
7. Consultation with specialist in the various field of medicine.
8. Hospital care in a standard ward for a stay limited to cumulative 30days per year.
9. Eye examination and care. Provision of low-priced glasses (excluding contact lenses) and at a shared cost in some services.
10. Dental care (excluding those on the exclusion list) and at a shared cost in some cases.
11. A range of prosthesis (limited to prosthesis produced in Nigeria) at a shared cost.
12. Annual medical checkup unrelated to illness.
13. Promotive and preventive care (including immunisation, health and family planning education)
Primary Healthcare Services
1
Services covered by capitation.
2
Entry point and point of first contact of enrolees with service providers.
3
Provides essential but basic health care services.
Services provided at this level
Access to promotive, preventive, curative and rehabilitative services to common ailments and injuries.
A. Internal Medicine
I. Malaria and other acute and uncomplicated febrile illnesses
II. Uncomplicated diarrhea disease
III. Acute upper respiratory tract infection
IV. Uncomplicated pneumonia
V. Mild anaemia (not requiring blood transfusion)
VI. Simple skin infections, e.g. Tinea infections, pityriasis versicolor, herpes zoster
VII. Worm infestation
VIII. Other uncomplicated bacteria, fungal, parasitic and viral infections.
IX. Follow-up treatment of chronic illnesses, e.g. hypertension, diabetes mellitus etc.
X. Dog bites, snake bites and scorpion bites
XI. Arthritis and common musculoskeletal diseases.
XII. Treatment of simple opportunistic infections in HIV/AIDS.
XIII. Other illnesses as may be updated and listed from time to time by BHIS.
B. Surgical Procedures
I. Drainage of simple abscess (I & D)
II. Minor wound debridement
III. Surgical repairs of simple lacerations
IV. Circumcision of male infants
V. Passage of urethral catheter
VI. Drainage of paronychia
VII. Other procedures as may be listed from time to time by BHIS.
C. Maternal and Child Health Services
a. Maternal Health Services
I. Routine care for uncomplicated pregnancies (Antenatal, Delivery and postnatal) i.e. 2nd, 3rd and 4th pregnancies
II. Family planning services; this includes family planning education only
III. Acute pelvic inflammatory disease
IV. Vaginal discharge
V. Other illnesses as may be listed from time to time by BHIS.
b. Childhood Health Services
I. Growth monitoring
II. Nutritional advice and health education
III. Routine immunisation based on the NPI schedule
IV. Treatment of common childhood illnesses e.g. (malaria, other febrile illnesses, vomiting and uncomplicated diarrhoea disease, uncomplicated malnutrition, failure to thrive, measles, SCD, upper respiratory tract infections, uncomplicated pneumonia, other childhood exanthema, simple skin disease and other viral illnesses.
D. Heath Education to prevent and control health problems
I. Voluntary counselling and testing (VCT) for HIV/AIDS and other STIs.
II. Health education and control of other communicable diseases e.g. cholera and non communicable diseases such as hypertension, diabetes mellitus etc.
E. Essential Drugs from Accredited Pharmaceutical shops
I. This is based on the BHIS essential drug and price list
II. Note that the beneficiary is expected to make a co-payment of 10% of the total cost of drugs prescribed
III. They are generic and not branded drugs
F. Accident and Emergency
An enrolee requiring emergency treatment shall visit his primary facility or the nearest BHIS accredited health facility. He is to be offered First Aid treatment before referral if necessary.
The Procedures include:
I. Establish an intravenous line
II. Establish patent airway
III. Control bleeding
IV. Cardiopulmonary resuscitation
V. Immobilisation of fractures (using splint, neck collars, etc.) to ease transportation of patient.
VI. Aspiration of mucus plug to clear airways.
VII. Management of convulsions.
VIII. Asthmatic attacks
IX. Passage of urinary catheter
X. Any other procedure that may be life saving.
G. Eye care Services
Treatment of minor eye ailments including:
I. Conjunctivitis.
II. Parasitic and allergic ailments
III. Simple contusion, abrasion, foreign bodies etc.
H. Other illnesses as may be listed from time to time by BHIS.
I. Mental Health Services
I. Anxiety neurosis
II. Psychosomatic illnesses
III. Insomnia
IV. Other illnesses as may be listed from time to time by BHIS
J. Laboratory and Diagnostic Services
I. Malaria parasite
II. White blood cell count (WBC)
III. Hemoglobin estimation and packed cell volume (PCV)
IV. Urinalysis
V. Stool and urine microscopy
VI. Widal test
VII. ESR
VIII. Blood grouping
IX. Blood sugar
X. Pregnancy test
XI. Blood film for microfilaria.
Secondary Healthcare Services
1
Offer specialised care on referral
2
Services covered by fee for service
A. Surgical procedures
All other procedures that can not be handled at the primary level of care can be undertaken at the secondary care level, depending on the complexity and the competence of the facility and its personnel, except those conditions requiring tertiary level of care or the exclusion list.
NOTE:
Hospital stay in orthopaedic cases is allowed for Six (6) cumulative weeks and does not in anyway foreclose post hospitalization management. The primary healthcare facility of the enrollee shall pay per diem for the first Fifteen (15) cumulative days of hospitalization while the BHIS shall pay for the remaining Twenty Seven (27) cumulative days per year.
B. Internal Medicine
All cases that cannot be treated at the primary level of care must be promptly referred to a secondary centre. Except those conditions requiring tertiary level of care or in the exclusion list.
C. HIV/AIDS
I. Management of cases requiring admission
II. Treatment of opportunistic infections
D. Paediatrics
All medical and surgical paediatric cases that cannot be handled at the primary level, except those requiring tertiary care or on the exclusive list
E. Obstetrics and Gynaecology
I. Specialist consultation
II. Multiple pregnancies/high-risk pregnancies
III. Caesarian section
IV. All Emergency gynaecological procedures
V. All primigravida and grand multigravida shall be managed at the secondary level of care.
VI. Other procedures that are not in the exclusion list.
F. Dental Health
I. Dental check
II. Scaling and polishing
III. Minor oral surgeries
IV. Maximum of two root canal treatment
V. Replacement of maximum of two dentures
G. Ophthalmology
I. Refraction, including provision of low-priced glasses, excluding contact lenses
II. All cases that can not be handled at the primary level except those requiring tertiary care or on the exclusion list
H. Ear, Nose and Throat (ENT).
All ENT cases that cannot be handled at the primary level except those requiring tertiary care or on the exclusion list.
I. Physiotherapy
All procedures except those in the exclusion list. Maximum of 12 cumulative sessions per year.
NOTE:
Hospital stay in CVA is allowed for Twelve (12) cumulative weeks and does not foreclose post hospitalisation therapy. The primary healthcare facility of the enrolee shall pay per diem for the first Fifteen (15) days of hospitalisation, while the BHIS shall pay for the remaining Sixty Nine (69) cumulative days per year.
J. Radiology/Ultrasonography
All investigations except those in the exclusion list.
NOTE:
All radiological imaging must be accompanied with its detailed report.
K. Emergency care
Acute stroke, acute renal failure (maximum of three sessions of dialysis), RTAs.
Tertiary Healthcare Services
1
Services covered by fee for service
2
All cases/procedures that cannot be handled at the secondary level except those on the exclusion list.
EXCLUSION
The following conditions are excluded from the benefit package of BHIS.
TOTAL EXCLUSION
a. Occupational/Industrial injuries to the extent covered under the Workman Compensation Act
b. Injuries resulting from;
- Natural disasters, e.g. earth quakes, land slides
- Conflicts, social unrest, riots, wars
c. Pandemics, epidemics and outbreaks
d. Family planning commodities, including condoms
e. Injuries arising from extreme sports, e.g. car racing, horse racing, boat racing, polo, mountaineering, boxing, wrestling, swimming, etc.
f. Drug abuse/addiction
g. Domiciliary visit
h. Surgical procedures as;
- Mammoplasty
- Transplant
- Cosmetic surgeries
- Implants
- Imported prosthesis
i. Ophthalmological procedures
- Provision of contact lenses.
j. Medical procedures.
- Cardiac pacemakers.
- Chronic renal failure requiring dialysis.
- Renal transplant.
k. Oncology.
l. Dental care.
- Implants.
m. Maxillofacial surgeries.
n. Pathology.
- Post mortem examinations and procedures.
- Histology/tissue examination.
PARTIAL EXCLUSION
a. High technology investigations, e.g. CT scan, MRI. BHIS shall pay 50% 0f the cost.
b. Congenital abnormalities (Diagnosis only).
c. Some dental procedures as in the BHIS guidelines.
d. Prosthesis.
e. Some ophthalmological procedures as in BHIS guidelines.
f. Other treatment and procedure as may be listed by BHIS from time to time.