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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.

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.

About BHIS

Bayelsa Health Insurance Scheme (BHIS) is a social security programme designed by the state government, where healthcare services of enrolees are paid from common pool of funds contributed by participants in the scheme.

Contact Details

Health Insurance House,
State Secretariat Complex,
Ovom, Yenagoa,
Bayelsa State.