NATIONAL HEALTH INSURANCE ACT

to provide for sound financing for the national health system; provide for a universal access to quality insured health care services; establish the National Health Insurance Management Authority and provide for its functions and powers; establish the National Health Insurance Scheme and provide for its systems, procedures and operation; establish the National Health Insurance Fund and provide for contributions to and payments from the Fund; provide for accreditation criteria and conditions in respect of insured health care services; provide for complaints and appeals processes; provide for the progressive establishment of provincial and district health offices of the Authority; and provide for matters connected with, or incidental to, the foregoing.

[2nd November, 2018]

Act 2 of 2018,

SI 83 of 2018.

PART I
PRELIMINARY PROVISIONS

1. Short title

This Act may be cited as the National Health Insurance Act.

2. Interpretation

In this Act, unless the context otherwise requires—

“accreditation” means the process of recognition of a health care provider as one that is allowed to provide insured health care services for the purposes of this Act;

“accredited health care provider” means a health care provider that is accredited by the Authority under section 28;

“actuarial assessment” means the periodic valuation of a Scheme, made in accordance with actuarial methods;

“admission” means a procedure where a person is accommodated overnight or for such other prescribed period by a health care provider for the purposes of receiving necessary in-patient services and “admitted” and cognate expressions shall be construed accordingly;

“Authority” means the National Health Insurance Management Authority established under section 4;

“bank” has the meaning assigned to the word in the Banking and Financial Services Act, 2017;

“benefit” means a direct insured health care service in the form of treatment or an indirect insured health care service consisting of a reimbursement of the expenses borne by a member and provided by an accredited health care provider and may include authorised tertiary health care services or a cash benefit;

“benefit package” means the benefits a member is entitled to under the Scheme;

“billing” means making a claim by an accredited health care provider for insured health care service expenses;

“Board” means the Board of the Authority constituted under section 6;

“casual employee” has the meaning assigned to the words in the Employment Act;

“Chairperson” means the Chairperson of the Board, appointed under section 6;

“child” has the meaning assigned to the word in the Constitution;

“citizen” has the meaning assigned to the word in the Constitution;

“committee” means a committee of the Board constituted under section 8;

“Council” means the Health Professions Council established under the Health Professions Act, 2009;

“dependant” means a person, who resides with a member, and relies on the member’s income for survival;

“emergency medical condition” means the sudden, and at the time unexpected onset of a health condition that requires immediate medical or surgical treatment, where failure to provide medical or surgical treatment would result in serious impairment to bodily functions or serious dysfunction of a body organ or part or would place the person’s life in serious jeopardy;

“employee” has the meaning assigned to the word in the Employment Act;

“employer” has the meaning assigned to the word in the Employment Act;

“established resident” has the meaning assigned to the word in the Immigration and Deportation Act, 2010;

“family member” means a registered child, spouse and dependant of a member;

“Fund” means the National Health Insurance Fund established under section 41;

“health care expense” means an amount payable in respect of an insured health care service provided to a member by an accredited health care provider;

“health care provider” includes an institution or agency that provides health care services;

“health care service” has the meaning assigned to the word in the Health Professions Act, 2009;

“health insurance number” means an identification number, assigned to a member by the Authority and stated on a member’s membership card;

“health practitioner” has the meaning assigned to the words in the Health Professions Act, 2009;

“inpatient service” means a health care service provided by a patient who is admitted overnight by a health care provider;

“inspector” means a person appointed as an inspector under section 40;

“insured health care service” means a health care service available under the Scheme;

“medical doctor” means a health practitioner registered as such under the Health Professions Act, 2009;

“member” means a member of the Scheme as provided under section 13;

“member contribution” means such amount as may be prescribed for purposes of section 15;

“membership card” means a card issued to a person registered under the Scheme;

“out patient service” means a health care service or procedure provided by a health care provider to a patient who is not admitted by a health care provider;

“patient” means a member who is receiving or has received treatment from an accredited health care provider;

“pension scheme” means a pension scheme established under any other law;

“private health insurer” means a company that provides health insurance;

“provider payment system” means the manner of payment to a health care provider for delivery of health services to members;

“Scheme” means the National Health Insurance Scheme established under section 12;

“treatment” means medical, surgical, obstetric or dental treatment or such other medical treatment as may be prescribed; and

“Vice-Chairperson” means the Vice-Chairperson of the Board elected under section 6.

3. Application and power of exemption

(1) The provisions of this Act shall bind the Republic.

(2) The Minister may prescribe health care services that are not covered by the Scheme.

(3) The Minister, by statutory instrument, may extend the categories of individuals to whom this Act applies.

PART II
THE NATIONAL HEALTH INSURANCE MANAGEMENT AUTHORITY

4. Establishment of National Health Insurance Management Authority

(1) There is established the National Health Insurance Management Authority which is a body corporate with perpetual succession and a common seal, capable of suing and being sued in its corporate name and with power, subject to this Act, to do all acts and things that a body corporate may, by law, do or perform.

(2) The Schedule applies to the Authority.

5. Functions of Authority

The functions of the Authority are to—

(a) implement, operate and manage the Scheme;

(b) manage the Fund;

(d) develop a comprehensive benefit package to be accessed by members;

(e) register and issue membership cards to members;

(f) facilitate—

(i) access by poor and vulnerable people to insured health care services; and

(ii) protection of the poor and vulnerable against deprivation of health services;

(g) receive, process and pay claims for services rendered by accredited health care providers;

(h) undertake public education and awareness programmes on health insurance;

(i) undertake research in health insurance to inform policy formulation and implementation;

(j) advise the Minister on health insurance and health insurance policy formulation;

(k) undertake programmes that further the sustainability of the Scheme;

(l) develop guidelines, processes and manuals for the effective implementation and management of the Scheme;

(m) ensure that an accredited health care provider delivers efficient and quality insured health care services;

(n) monitor and ensure compliance with this Act and guidelines, policies, processes and manuals made by the Authority in the performance of its functions under this Act;

(o) undertake, in collaboration with relevant regulatory agencies, inspection of health facilities operated by accredited health care providers;

(p) receive, investigate and determine complaints by members and accredited health care providers in accordance with section 49;

(q) collaborate with corresponding health insurance management authorities in other countries;

(r) develop, in consultation with relevant stakeholders, modalities of financing the coverage of indigent people under the Scheme;

(s) cause the undertaking of actuarial valuations of the Scheme at prescribed intervals;

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