National Mobile Health Insurance Programme

1. National Mobile Health Insurance Programme Benefits Package

2. PRIMARY BENEFITS PACKAGE Health preventive, promotive and rehabilitative services such as health education, immunization, counseling and testing for HIV/AIDS, etc Access to care for defined medical and surgical conditions, covering consultation, laboratory investigations, pharmaceuticals, etc. Essential pharmaceuticals from NHIS accredited pharmacy providers including provision of needed pharmaceutical care from pharmacists (beneficiaries to pay 10% of the cost of pharmaceuticals as co-payment) All drugs are generics as contained in the essential drug list of the FMoH Routine laboratory investigations Maternal and child health services Primary eye care, dental and mental health services Accident and Emergency services

3. Primary Surgery Services Incision and drainage of abscess (I&D) Wound debridement Repair of lacerations Circumcision of male infants Drainage of Paronychia Evacuation of impacted faeces Correction of simple polydactyl

4. Primary Medical Services Malaria and other acute febrile illnesses that can be managed at the primary level of care Diarrhoel diseases Acute respiratory tract infections Urinary tract infections Simple skin diseases such as T. Vesicolor, T. Capitas, M. Furfur, etc. Worm infestation (Helminthiasis) Other uncomplicated bacterial, fungal, parasitic and viral illnesses Diagnosis and follow-up management of hypertension Follow up management of Diabetes, Asthma, Sickle Cell Anaemia, Glaucoma, etc Arthritis and other musculoskeletal disorders Dog bite, Snake bite, Scorpion sting, etc. Voluntary Counseling and Testing for HIV/AIDS and the treatment of opportunistic infections Management of uncomplicated mental illnesses such as insomnia, anxiety neurosis, etc Management of acute Pelvic inflammatory disease and vaginosis Routine Antenatal care, delivery & postnatal care for low risk pregnancies (2nd 3rd & 4th pregnancies) Health education on family planning services (Safe period, condoms, pills, implant, etc) Treatment of minor eye ailments, including conjunctivitis, simple contusion, abrasions, etc

5. Emergency Care Management of emergencies should aim at stabilization at the primary level of care before referral. Common conditions/procedures under emergency care include but not limited to: Management of convulsions, coma, etc Management of asthmatic attack Management of sickle cell crisis Management of shock Simple tracheostomy Control of bleeding Cardio-respiratory resuscitation Immobilization of fractures (using splints, neck collars, etc)

6. Primary Paediatric Services An infant to a registered mother is covered for a period of 12 weeks after delivery Health education, growth monitoring, nutritional advice and routine immunization services Management of childhood vaccine preventable illnesses Malaria and other acute febrile illnesses that can be managed at the primary level of care Diarrhoel diseases Acute respiratory tract infections Urinary tract infections Simple skin diseases such as T. Vesicolor, T. Capitas, M. Furfur, etc. Worm infestation (Helminthiasis) Other uncomplicated bacterial, fungal, parasitic and viral illnesses Management of Asthma, Sickel Cell Anaemia Dog bite, Snake bite, Scorpion sting, etc Nutritional disorders

7. SECONDARY SERVICES Consultation with specialists and specialist care for Medicine, Surgery, Psychiatry, Obstetrics & Gygnaecology, ENT, Ophthalmology and Paediatrics Hospitalization in general ward for a cumulative period of a maximum of 21 days per annum Physiotherapy for restoration and rehabilitation Medical imaging (radiology, ultrasonography, etc.) Diagnostic laboratory services not covered at the primary level Prescribed pharmaceuticals (generics) on the essential drug list of the FMoH

8. Secondary Medical Services Services at this level include consultation with specialist physician. All medical cases that cannot be handled at the primary level are managed at the secondary/tertiary level upon referral. These include but not limited to: Complicated Hypertension and diabetes Management of stroke, including hospitalization Management of Chronic liver disease, Heart failure, Complicated respiratory tract infections, Management of allergies and other complicated skin conditions Management of HIV/AIDS requiring admission, including treatment of opportunistic infections.

9. Secondary/Tertiary Surgical Services Benefits at this level include consultation with specialist surgeon and all surgical procedures not covered at the primary level and not in the exclusion list, such as : Appendicectomy, herniorhapy, hydrocelectomy, splenectomy, removal of renal stones, prostatectomy, gall bladder surgeries, peptic ulcer surgeries, etc Orthopaedic surgeries, including management of fractures. Insertion of chest tubes, etc Provision of locally made prosthesis

10. Secondary/Tertiary Paediatric Services Benefits at this level include consultation with a Paediatrician. All paediatric medical conditions that cannot be handled at the primary level and are not on the exclusion list are managed at the secondary/tertiary level upon referral. These include but not limited to: Neonatal incubation services for a maximum period of 12 weeks Phototherapy & exchange blood transfusion services Management of simple congenital anomalies such as cleft lip and cleft palate, etc Management of complicated infections and infestations such as severe malaria, meningitis, pneumonia, etc. Management of failure to thrive Management of palsies Management of allergies and other complicated skin conditions Management of HIV/AIDS requiring admission

11. Obstetrics & Gygnaecological Services Specialist consultation with obstetrician & gynaecologist Antenatal care, delivery and postnatal care for high risk pregnancies (1st pregnancy, multiple pregnancies, 4th pregnancy and beyond, Pregnancy with superimposed medical conditions, etc) Management of ectopic pregnancy Caesarean section Management of other gynecological conditions such as ovarian cyst, polycystic ovarian syndrome, etc Management of infertility excluding assisted reproductive methods such as IVF, ICSI, etc. Hysterectomy Pelvic prolapse surgery Other obstetric and gynecological conditions not in the exclusion list

12. Ophthalmological Services Specialist consultation with an ophthalmologist Management of eye conditions such as foreign body removal, pterygium excision, cataract extraction, glaucoma, etc. Refraction Other ophthalmological conditions not in the exclusion list

13. Ear, Nose & Throat (ENT) Services • Consultation with ENT surgeon • Removal of foreign bodies • Antral wash out • Tonsillectomy • Polypectomy • Tracheotomy • Adenoidectomy • Any other procedure not in the exclusion list

14. Mental Health Services • Consultation with specialist • Management of Psychosis • Manic -Depressive illnesses • Schizophrenia, etc • Others conditions not on the exclusion list

15. Dental Services Tooth extraction and amalgam filling

16. Physiotherapy Services Consultation with a specialist Palsies within 15 days following initial treatment Post trauma rehabilitation CVA therapy within 15 days Post surgery rehabilitation within prescribed 15 days.

17. TOTAL EXCLUSION Total Exclusions • Domiciliary visit • Medical check up unrelated to illness • Epidemics • Injuries resulting from: - natural disasters e.g earthquake, landslide, etc. • Conflicts, social unrest, riots, wars, etc. • Extreme sports e.g car racing, horse racing, polo, boxing, wrestling, etc. • Occupational/ industrial injuries( covered under the Workman Compensation Act) • Transplant and cosmetic surgeries • High cost surgical procedures • Organ transplant • Open heart surgery • Neurosurgery (excluding borehole) • Laminectomy, etc

18. High tech investigation except in life threatening emergencies, e.g CT Scan, MRI Family planning commodities Drug abuse/ addiction Terminal illnesses including all cancers Provision of spectacles, contact lens, etc. Hearing aids and associated appliances Management of Tuberculosis, Leprosy, Chronic renal failure Congenital anomalies involving major/extensive surgical repairs, e.g separation siamese twins, omphalocoele, etc Chronic congenital defects e.gHirschsprung’s disease , etc Management of infertility involving IVF, ICSI, etc Dentures, crowns, bridges, implants, scaling and polishing Maxillofacial surgeries Root canal treatment

19. PARTIAL EXCLUSION Life saving emergencies requiring high technology investigations (MRI, CT Scan, etc) Screening e.g Pap smear, mammogram, etc HMO pays 20% of the cost