1. Introduction

This Health Insurance Policy Document outlines the benefits, terms, conditions, and procedures governing the healthcare coverage for eligible enrollees on the Edo State Contributory Health Insurance Scheme, hereinafter referred to as the Scheme.

The purpose of this document is to provide a clear and comprehensive guide to the healthcare services available to enrollees, including the benefit package, access protocols, and rights and responsibilities.

This policy has been developed in accordance with the National Health Insurance Authority Act, 2022, Edo State Health Insurance Law 2019 and other applicable regulations issued by the Edo State Government and EDOHIC.

2. Definition of Key Terms

• Commission - Edo State Health Insurance Commission (EDOHIC).
• Scheme - Edo State Contributory Health Insurance Scheme.
• Healthcare Facility - A facility licensed by the Ministry of Health and accredited by the commission to provide services.
• Residents - A person who resides in Edo State.
• Enrollees - A person who has purchased a Health plan and issued an identity card with a Corporate Insurance Number (CIN).
• Health Plan - A structured package of healthcare benefits offered in exchange for a premium.
• Pre-existing Condition - A health condition or illness a person had prior to the commencement of coverage.
• Co-Payment - A fee paid by an enrollee for selected covered services, while the Commission covers the rest.
• Emergency Services - Urgent medical treatments provided to prevent serious harm, disability, or death.

3. Enrollees Eligibility

All Residents of Edo State shall be eligible to enroll on the scheme. Per the NHIA Act 2022 and Edo State Health Insurance Law 2019, the Scheme is mandatory for all residents of the State.

4. Enrollment Process

1. Choose a Health Insurance Plan.
2. Pay the required premium.
3. Fill an enrollment form.
4. Submit required documents (Valid ID, NIN, proof of employment, passport photograph).
5. Assignment to a healthcare facility.

5. Rights of Enrollees

• Right to access quality and timely healthcare services at an assigned facility.
• Right to receive complete treatment and generic medications for covered services.
• Right to dignity, respect, and confidentiality.
• Right to clear information regarding benefits, limits, and exclusions.
• Right to referrals for specialist care when necessary.

6. Responsibilities of Enrollees

• Provide accurate and complete information during registration.
• Present EDOHIC ID or CIN when accessing care.
• Access care at the assigned facility.
• Pay 10% for covered drugs and lab investigations, and 50% co-payment for selected services.
• Renew health plan premium before expiration.

7. Waiting Period

A 30-day waiting period applies after enrollment before an enrollee is eligible to access services. Eligibility begins the first day of the month after this period elapses.

7.1 No Benefit During Waiting Period

No coverage is in force during the waiting period; EDOHIC is not liable for costs incurred during this time.

7.2 Indemnity and Pre-existing Conditions

Enrollees must indemnify EDOHIC if services are obtained during the waiting period. For pre-existing conditions, enrollees are not eligible for coverage until they have been on the scheme for six months.

8. Access to Services

Enrollees must access care at assigned facilities. Emergency services may be accessed at the nearest accredited facility, provided EDOHIC is notified within 24 hours.

9. Benefit Package

Enrollees are entitled only to services contained in their respective Health Plan as outlined in the Benefits Package document.

10. Renewal and Termination

Plans are valid for 12 months and must be renewed to avoid termination. Enrollment may be terminated due to death, retirement (formal sector), non-payment (informal sector), or fraud.

12. Grievance and Dispute Resolution

Enrollees have the right to file written complaints, which will be investigated and the resolution communicated.

14. Enrollee Acknowledgment

By clicking "I Agree," the enrollee acknowledges reading and understanding the terms of the Edo State Health Insurance Scheme and agrees to abide by the rights and responsibilities outlined.