NATIONAL HEALTH INSURANCE ACT: SUBSIDIARY LEGISLATION

INDEX TO SUBSIDIARY LEGISLATION

National Health Insurance Act (Commencement) Order

National Health Insurance (General) Regulations

NATIONAL HEALTH INSURANCE ACT (COMMENCEMENT) ORDER

[Section 1]

Arrangement of Paragraphs

   Paragraph

   1.   Title

   2.   Commencement of Act No. 2 of 2018

SI 83 of 2018.

1.   Title

This Order may be cited as the National Health Insurance Act (Commencement) Order, 2018.

2.   Commencement of Act No. 2 of 2018

The National Health Insurance Act, 2018, shall come into operation on the date of publication of this Order.

NATIONAL HEALTH INSURANCE (GENERAL) REGULATIONS

[Section 57]

Arrangement of Regulations

   Regulation

   1.   Title

   2.   Interpretation

   3.   Registration as member

   4.   Application for health insurance by foreigner

   5.   Membership card

   6.   Replacement of membership card

   7.   Change of membership status

   8.   Removal of member from Scheme

   9.   Contribution rates

   10.   Benefit package and payment mechanisms

   11.   Application for accreditation

   12.   Criteria for accreditation

   13.   Display of certificate of accreditation

   14.   Suspension or revocation of accreditation

   15.   Reporting requirements for accredited health care provider

   16.   Payment of claims for insured health care services

   17.   Confidential patient record system

   18.   Accredited health care provider payment health system

   19.   Percentage of monies to be disbursed

   20.   Register

   21.   Complaints

   22.   Fees

      FIRST SCHEDULE

      SECOND SCHEDULE

      THIRD SCHEDULE

      FOURTH SCHEDULE

      FIFTH SCHEDULE

SI 63 of 2019.

1.   Title

These Regulations may be cited as the National Health Insurance (General) Regulations, 2019.

2.   Interpretation

In these Regulations unless the context otherwise requires-

"benefit package"  means the benefit package set out in the Fourth schedule;

"certificate of accreditation"  means a certificate of accreditation issued under regulation 11;

"citizen"  has the meaning assigned to the word in the Constitution;

"clinic"  means a health facility that provides outpatient services and includes a health facility that provides dental and vision care;

"Committee"  means the Health Complaints Committee of the Board continued under the Act;

"employee"  has the meaning assigned to the word in the Employment Code Act, 2019;

"employer"  has the meaning assigned to the word in the Employment Code Act, 2019;

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

"hospice"  means a place where a person who is terminally ill receives palliative care;

"hospital"  means a health facility that provides inpatient and outpatient services;

"member"  has the meaning assigned to the word in the Act;

"membership card"  means the membership card issued to a member under regulation 5; and

"register"  means a register established by the Authority under regulation 18;

"Zambia Medicines Regulatory Authority"  means the Zambia Medicines Regulatory Authority established under the Medicines and Allied Substances Act, 2013.

3.   Registration as member

   (1) Subject to sub-regulations (2) and (3), an eligible citizen or established resident shall register as a member of the Scheme in Form I set out in the First Schedule.

   (2) An employer shall register an employee with the Authority as a member in Form I set out in the First Schedule.

   (3) A manager of a pension scheme shall register a retiree under that pension scheme as a member in Form I set out in the First Schedule.

4.   Application for health insurance by foreigner

A foreigner who enters the Republic without valid health insurance, shall, on arrival in the Republic at the port of entry, apply to a health insurance for health insurance in Form II set out in the First Schedule on payment of a fee determined by the health insurer.

5.   Membership card

   (1) The Authority shall, within 60 days of receipt of registration in Form I under regulation 3, issue a membership card in Form III set out in the First Schedule.

   (2) A member shall, on receipt of the membership card under sub-regulation (1), present the membership card to an accredited health care provider in order to access a benefit package.

6.   Replacement of membership card

   (1) A member whose membership card is lost, defaced or destroyed shall apply to the Authority for a replacement card in Form IV set out in the First Schedule on payment of the fee set out in the Second Schedule.

   (2) The Authority shall, within 30 days of receipt of an application under sub-regulation (1), issue a replacement membership card in Form III set out in the First Schedule.

7.   Change of membership status

A member shall inform the Authority of any change in the membership status of that member in Form V set out in the First Schedule.

8.   Removal of member from Scheme

A person ceases to be registered as a member under the Scheme if that person dies, ceases to be a citizen or established resident.

9.   Contribution rates

An employer or self-employed citizen or established resident shall pay to the Scheme a contribution consisting of the employer's contribution and the employee's contribution at the rates set out in the Third Schedule.

10.   Benefit package and payment mechanisms

   (1) A member is entitled to the benefit package set out in the Fourth Schedule.

   (2) An employer or self-employed citizen or established resident who fails to pay a contribution or remit a contribution of an employee due to the Scheme as set out under sub-regulation (1) commits an offence for the purposes of section 53 of the Act.

   (3) Despite sub-regulation (2), where an employer fails to pay an unremitted contribution owed by an employer due to the Scheme, the unpaid amount shall be a civil debt due to the Scheme and shall be summarily recoverable.

11.   Application for accreditation

   (1) A health care provider that wishes to provide an insured health care service to a member shall apply to the Authority for accreditation in Form VI set out in the First Schedule on payment of the fee set out in the Second Schedule.

   (2) The Authority shall, where it approves an application, issue the health care provider with a certificate of accreditation in Form VII set out in the First Schedule.

   (3) The Authority shall, where it rejects an application for accreditation, inform the applicant in Form VIII set out in the First Schedule.

12.   Criteria for accreditation

The Authority shall accredit a health care provider if the health care provider-

   (a)   has the capacity to deliver the insured health care services determined by the Authority; and

   (b)   passes a physical inspection carried out by the Authority of the facility used by the health care provider.

13.   Display of certificate of accreditation

An accredited health care provider shall display the certificate of accreditation in a conspicuous place at the place of practice.

14.   Suspension or revocation of accreditation

   (1) The Authority shall, where it intends to suspend or revoke an accredited health care provider's accreditation, notify the accredited health care provider of its intention to suspend or revoke the accreditation in Form IX set out in the First Schedule.

   (2) The Authority shall, notify an accredited health care provider of the suspension or revocation of accreditation in Form X set out in the First Schedule.

15.   Reporting requirements for accredited health care provider

An accredited health care provider shall provide the Authority with a report of insured health care services in the format set out in the Fifth Schedule.

16.   Payment of claims for insured health care services

   (1) An accredited health care provider that provides a health care service to a member, shall submit a claim to the Authority in Form XI set out in the First Schedule.

   (2) The Authority shall, on receipt of a claim under sub-regulation (1), assess the claim and pay the accredited health care provider of a valid claim.

17.   Confidential patient record system

   (1) An accredited health care provider shall establish and maintain an accurate, confidential patient record system in accordance with any relevant written law and health standards as may be determined from time to time.

   (2) The confidential patient record system refereed to in sub-regulation (1) shall provide for-

   (a)   unique membership identification;

   (b)   nature of benefits to be accessed by each member;

   (c)   personnel authorised to access the system;

   (d)   a legible, traceable and auditable format; and

   (e)   integrity of the patient's records.

18.   Accredited health care provider payment system

   (1) An accredited health care provider shall establish and maintain a payment system that allows the Authority to receive, verify and settle claims.

   (2) The payment system referred to in sub-regulation (1) shall have the ability to-

   (a)   submit claims manually or electronically;

   (b)   keep records of claims submitted by the accredited health care provider;

   (c)   use standardised claim forms; and

   (d)   produce periodic statements for verification by the Authority.

19.   Percentage of monies to be disbursed

The Authority shall not, in any year, expend more than 10 per cent of the monies held by the Fund in that year on activities or programmes referred to in section 41(2)(b) and (c) of the Act.

20.   Register

The Authority shall establish and maintain a register of members, employers, pension schemes, self-employed citizens or established residents and accredited health care providers in Form XII set out in the First Schedule.

21.   Complaints

A member or an accredited health care provider may lodge a complaint to the Committee or Board in Form XIII set out in the First Schedule.

22.   Fees

The fees set out in the Second Schedule are the fees payable for the matters specified therein.

FIRST SCHEDULE

[Regulations 3, 4, 5, 6, 7, 11, 14, 16, 20, 21 and 22]

Form I

[Regulation 3]