The vast majority of Nigerians are only just coming across health insurance for the first time and it often seems so hard to understand what exactly a plan does for you. This is partly because of the unfamiliar words used in the industry, we break down some of these in very simple terms.
Insurance plans can differ in a number of ways from which hospitals you can go to, what services you are covered for and how much you pay.Navigating these requires a good grasp of the terms so you can make the right choices for yourself and not get lost in the vocabulary maze.
HMO: This term stands for ‘Health Maintenance Organisation’ and in Nigeria is the catch-all term for companies offering health insurance plans. Hygeia HMO, for example, offers access to care to all members within its network of hospitals and other providers in its network. An HMO generally won’t cover out-of-network care except in an emergency.
Network: The doctors, hospitals, and providers your HMO has contracted with to deliver health care services to their members.
Health Plan: is a contract between you (or a sponsor like an employer) and an HMO to provide access to designated health services needed by plan members for a fixed, prepaid premium. Plans vary widely from general plans to more specific ones like a dedicated maternity plan
Premium: A premium in insurance terms is simply what you pay in advance for your health plan. This is the price you see quoted for plans, usually a fraction of the benefits you stand to gain.When shopping for a plan, keep in mind that the plan with the lowest premium may not be the best match for you.
Benefits: What are benefits? These are the package of medical services such as tests, drugs and treatments included in your health plan. The plan usually sets a limit to these benefits. These limits are agreed upfront per plan for full transparency.
Out of Pocket: This refers to the medical costs that you pay yourself and are not reimbursable by the HMO. So when you go the hospital without health insurance, you always pay “out of pocket”. When you go for a service that is excluded from your health plan, you also pay out of pocket.
Exclusion: Exclusions refers to all the services the HMO will not cover. These exclusions can vary from plan to plan and it is essential you get to know what is excluded from your plan. Hygeia HMO plans have clearly described exclusions on each plan page.
Waiting Period: This is the time that must pass before coverage becomes effective in general and for specified services. All Hygeia HMO personal and family plans have a 14 day waiting period, some plans also have a 2 or 3 month waiting period for services like chronic drug refills or dental care.
Inpatient or Outpatient: These just address coverage limits where patients are admitted to the hospital to get care versus when they are not.
PA: Some benefits on your plan are only available with pre-authorisation by the HMO. Here, the hospital will need to get approvals from the HMO before the service is provided. Pre-authorisation does not generally apply to life-saving treatment in emergencies.
Investigations: Medical tests or procedures performed to detect, diagnose, or monitor diseases or to determine a course of treatment.
Capitation: is a fixed, pre-arranged monthly payment received by the hospital from the HMO. These payments are fixed regardless of how often the patient uses the service but restricts members to that specific hospital.
Fee for Service(FFS): it is a payment module where doctors and other health care providers receive a fee for each service such as consultations, tests or procedures. Payments are made only after services are provided.
These should get you brushed up and squared away on health insurance terms. Is there anything you have heard that we missed out on? Add them to the comments and we will update the post to explain them. Please share!