The Health Maintenance Organizations are crucial to the smooth running of the health insurance system as they are the link between the purchaser of health insurance and the service provider. They are, however, increasingly being seen as a major problem within the health insurance system in Nigeria with many subscribers called enrollees lamenting that they are often cheated by the HMOs. AMARACHI OKEH reports
As a first-time mom, Mrs. Precious Chidi, a health worker, was relieved that her company had enrolled her and other staff members under the company’s health insurance plan with a Health Maintenance Organization.
This meant that using her health insurance would greatly reduce or even eliminate the expenses the expectant family would have to make during antenatal care and delivery and thus help the family to save up money for the newborn.
But according to her, the HMO which is supposed to make access to healthcare seamless for her has been a major source of frustration for her.
Sharing her experience with PUNCH HealthWise, the Lagos-based woman said, “My company had switched to a new HMO and the firm gave us a list of what we are covered for and the hospitals we can access.
“During one of my antenatal visits, the doctor asked that I carry out an anomaly investigation and this is supposed to be covered in my plan.
“My name was sent to the HMO but it was not approved.”
She said she called the HMO’s customer service to understand why the request was not approved, but the customer rep she spoke with told her that the investigation she requested was indeed covered in her plan.
“I told her what she said contradicts what was sent to the hospital. She asked me to hold on, only to get back to me saying that it cannot be approved. She said that there was no indication for the investigation even after the doctor himself spoke with the HMO.”
Mrs. Precious who is a health worker explained that “ANC comes as a package and once you pay for it, it covers a whole lot of investigations, now saying that a pregnant woman of 19 weeks is not covered for an anomaly scan was very ridiculous and annoying .
“I don’t know the need of an HMO. If they claim to acknowledge a whole lot, but when you need them, they use flimsy excuses like no indication to not approve things,” she lamented.
According to experts, an anomaly scan or 20-week ultrasound is one of the scans a pregnant woman undergoes. This scan evaluates the anatomical structures of the fetus, placenta, and maternal pelvic organs. It is an important component of routine prenatal care.
Precious said the frustration of going back and forth for a service she is entitled to makes her pay out of pocket for even a service that is deducted monthly from her salary.
Precious is one of many Nigerians who decry the quality of service they continually endure from health management organizations that are meant to make access to healthcare seamless, cheaper, and easier for subscribers.
What are the roles of HMOs?
The Federal Government of Nigeria Act 35 of 1999 established the National Health Insurance Scheme but it was launched six years later in 2005. It was established to help improve access to healthcare for all Nigerians at an affordable cost.
However, the President, Major General Muhammadu Buhari (retd.), last May, signed into law, the National Health Insurance Authority Bill 2022. The bill repeals the National Health Insurance Scheme Act of 1999 and establishes the National Health Insurance Authority.
The health insurance was to help expand access to affordable health services for Nigerians.
It could be recalled that following the creation of the NHIS, the HMOs were licensed to provide health insurance for Nigerians.
The HMOs are insurance companies that manage the provision of healthcare services through various healthcare facilities.
At the moment, there are 59 HMOs listed on the official site of the National Health Insurance Authority.
These HMOs market their services to companies and individuals who desire healthcare insurance services. However, the bulk of clients of these HMOs are companies that procure health insurance packages for their staff.
When an agreement is reached between the HMO and the company on the health plan to provide for the employees, the company proceeds to pay the HMO premium. The premium is the amount a subscriber for health insurance (an enrollee) pays in exchange for access to an agreed set of healthcare services benefits for a fixed period.
Premiums can differ because of the number of people to cover, the amount of coverage to be enjoyed or the specific choice of hospitals
With a premium – which partly comes monthly from the salary of the workers -paid, the employees are covered to access health services covered by the plan subscribed to within a specific period.
However, as simple as this looked, implementing it has not been straightforward since the beginning of the health insurance operation in Nigeria.
There has been widespread dissatisfaction among subscribers of the various HMOs with consistent accusations of cheating and unsatisfactory services coming from many subscribers.
They make all sorts of pledges but hardly deliver on promises – Enrollee
Another health insurance subscriber lamenting about the services of the HMO is Stephen Chukwu (Not real name) who says his family patronises an HMO that has failed to deliver as expected.
The 31-year-old media practitioner who spoke with our correspondent under anonymity said the HMOs are often quick to make all sorts of pledges on the services they will provide, but hardly delivered on them.
He alleged that his family was cheated by HMO.
He said that his mother was forced to seek better care at another health facility and pay out of pocket because of the frustration the family was getting from the HMO.
Speaking with PUNCH HealthWise, he said his mother had fallen ill and gone to the Redemption Health Center where she is registered, noting that after confirming that her HMO was still active, she proceeded to see the doctor.
“After meeting with the doctor, she was required to do some blood tests to determine the right treatment and it was at this point that things changed,” he said.
“My mother had gone to where the blood sample was to be taken, but they simply refused even after she explained that her health package covered the procedure.
“Instead, she was given a note which I saw. The note asked the doctor to administer some drugs as the blood test would not be possible unless she paid cash.
“In the end, she was given some drugs. The drugs she was given were cheap medicines. One of the drugs was paracetamol. The whole experience left her sad,” he said.
“The disparity between what was promised and what was delivered is a wide gulf.
“There seems to always be some sort of scheming to ensure patients are not provided the services they ought to get under their health insurance plan.