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
2. Commencement of Act No. 2 of 2018
SI 83 of 2018.
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
4. Application for health insurance by foreigner
6. Replacement of membership card
7. Change of membership status
8. Removal of member from Scheme
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
SI 63 of 2019.
These Regulations may be cited as the National Health Insurance (General) Regulations, 2019.
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.
(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.
(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.
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.
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.
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.
The fees set out in the Second Schedule are the fees payable for the matters specified therein.
[Regulations 3, 4, 5, 6, 7, 11, 14, 16, 20, 21 and 22]
Form I
[Regulation 3]
THE NATIONAL HEALTH INSURANCE MANAGEMENT AUTHORITY |
The National Health Insurance Act, 2018 |
The National Health Insurance (General) Regulations, 2019 |
APPLICATION FOR REGISTRATION AS MEMBER |
Application No.: ............... |
INSTRUCTIONS |
1. Complete this form in one (1) copy. |
2. Complete the applicable portions only. |
3. Type or print all entries in BLOCK/CAPITAL LETTERS. |
4. This form shall be submitted to any of the following- |
(a) The Employer, if employed; |
(b) The Pension Scheme Manager, if retired; |
(c) On-line; |
(d) Head Office of the National Health Insurance Management Authority; or |
(e) Any other institution designated by the Authority. |
REQUIREMENTS |
1. Submit a certified true copy of your proof of marriage, if married. |
2. Submit a certified true copy of the Birth Certificate or poof of adoption, if the beneficiary is a child. |
3. Passport size photos for the applicant and all beneficiaries. |
4. A certified true copy of the National Registration Card. |
5. Valid permit for foreign nationals. |
PART A (Mandatory for ALL applicants) |
A. Personal Details: Citizen/Established Resident |
Prof. |
Full Names (as they appear on NRC or Passport) |
Surname Forename Other names |
........................................................................................................................................................... |
........................................................................................................................................................... |
NRC Number: |
Passport Number: |
Marital status: Married |
If married provide the following information in relation to your spouse: |
Surname Forename Other names |
........................................................................................................................................ |
........................................................................................................................................ |
Date of Birth (dd/mm/yy):............../.........../....... NRC Number : |
Passport Number: |
Date of marriage (dd/mm/yy): ......./........./........ Work Permit No: |
Foreigner {mprestriction ids="2,3,5"} B. Contact Details: |
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Physical Address | Postal Address: |
House Number: | ............................................................. |
............................................................ | ............................................................ |
............................................................ | ............................................................ |
Village (where applicable): | Town: |
............................................................ | ............................................................ |
............................................................ | ............................................................ |
Chief (where applicable): | District: |
............................................................ | ............................................................ |
............................................................ | ............................................................ |
Street Name: | Province: |
............................................................ | ............................................................ |
............................................................ | ............................................................ |
Town ................................................... | |
........................................................... | |
District: ................................. | |
........................................................... | |
Province: ................................... | |
........................................................... | |
Contact Number:......................... | |
.......................................................... | |
Email address: ............... | |
.......................................................... |
PART B |
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Salaried employee | Self-employed citizen/established resident | Retiree | Student | Other (Please specify) |
1. Salaried Employee |
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1.1 To be filled in by the Employee | 1.2 To be filled in by the Employer |
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Name of Employer: | We do confirm that, ......................... bearer of NRC Number |
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Address of Employer: | Permit Number |
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Employment Number: | I confirm that the information provided is correct to the best of our knowledge and belief: |
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Date of commencement | Name: .......................... |
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Position: ......................... |
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(dd/mm/yy) ........./ | Signature: .......................... |
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Date (dd/mm/yy) ........./............./..... |
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2. Self-employed |
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Tick appropriate box(es) that apply: | Average income per month: .......................... |
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2.1 |
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2.2 |
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2.3 |
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2.4 |
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2.5 |
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2.6 |
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2.7 |
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2.8 |
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2.9 |
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3. Retiree: Early |
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3.1 To be filled in by the Pension Scheme Manager | 3.2 To be filled in by the Pension Scheme Manager |
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Name of Pensioner Scheme: | We do confirm that .......................... bearer of NRC Number |
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...................................... | .................................................................................................. |
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....................................... | and became a member on the .................. of ......., 20.... |
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Address of Pension Scheme: | We confirm that the information provided is correct to the best of our knowledge and belief. |
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......................................... | Name: ............................................ |
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Pension Number: | Position: ...................................... |
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Date of Retirement: (dd/mm/yy) | Signature: .......................................... |
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....../............../.............. | Date: (dd/mm/yy) .............../.../..... |
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4. This section applies to students above the age of 18 years to whom the sections above do not apply. | |
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If covered attach copy of membership card. |
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If not covered complete section below. |
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1.1 To be filled in by Student | 1.2 To be filled in by Training Institution |
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Name of Student ................... ........................................... | We do hereby confirm that ....... bearer of NRC Number |
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Name and address of Training Institution ........................................ |
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I hereby confirm that the information provided is correct to the best of our knowledge. |
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Student Number ...................... | Name ................. |
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Position ........... |
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Signature................................ |
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Date of commencement with current training institution | Date (dd/mm/yy) ........./......../..... |
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(dd/mm/yy) ........../........./......... |
Normal PART C |
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1. Beneficiaries (please use separate sheet if necessary) |
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Last Name | First Name | Gender (F/M) | Date of Birth (dd/mm/yy) | NRC No./ Passport No. | Relation to Member |
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1. | ||||||
2. | ||||||
3. | ||||||
4. | ||||||
5. | ||||||
6. | ||||||
7. | ||||||
8. | ||||||
9. | ||||||
10. | ||||||
Attach passport photos of proposed member and beneficiaries below |
Member | Spouse | Child/ | Child/ | Child/ | Child/ | Child/ | Child/ |
CERTIFICATION BY APPLICANT |
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I CERTIFY THAT THE INFORMATION AND ALL STATEMENTS PROVIDED ARE TRUE AND CORRECT TO THE BEST OF MY KNOWLEDGE AND BELIEF | SIGNATURE OF APPLICANT: |
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.................... |
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DATE: (dd/mm/yy) |
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FOR OFFICIAL USE ONLY |
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DOCUMENTS SUBMITTED WHERE APPLICABLE | RECEIVED BY: |
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1. | DATE: (dd/mm/yy) ../.../... |
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2. | |||||||
3. | APPROVED BY: |
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4. |
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5. | DATE: (dd/mm/yy) ../.../... |
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6. | |||||||
7. |
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Membership Number Allocated: |
Form II
[Regulation 4]
THE NATIONAL HEALTH INSURANCE MANAGEMENT AUTHORITY |
The National Health Insurance Act, 2018 |
The National Health Insurance (General) Regulations, 2019 |
TRAVEL INSURANCE REGISTRATION |
Form III
[Regulations 5(1) and 6(2)]
THE NATIONAL HEALTH INSURANCE MANAGEMENT AUTHORITY |
The National Health Insurance Act, 2018 |
The National Health Insurance (General) Regulations, 2019 |
MEMBERSHIP CARD |
Form IV
[Regulation 6(1)]
THE NATIONAL HEALTH INSURANCE MANAGEMENT AUTHORITY |
The National Health Insurance Act, 2018 |
The National Health Insurance (General) Regulations, 2019 |
APPLICATION FOR REPLACEMENT OF MEMBERSHIP CARD |
Form V
[Regulation 7]
THE NATIONAL HEALTH INSURANCE MANAGEMENT AUTHORITY |
The National Health Insurance Act, 2018 |
The National Health Insurance (General) Regulations, 2019 |
CHANGE OF MEMBERSHIP STATUS |
Form VI
[Regulation 11(1)]
THE NATIONAL HEALTH INSURANCE MANAGEMENT AUTHORITY |
The National Health Insurance Act, 2018 |
The National Health Insurance (General) Regulations, 2019 |
APPLICATION FOR ACCREDITATION AS HEALTH CARE PROVIDER |
Form VII
[Regulation 11(2)]
THE NATIONAL HEALTH INSURANCE MANAGEMENT AUTHORITY |
The National Health Insurance Act, 2018 |
The National Health Insurance (General) Regulations, 2019 |
CERTIFICATE OF ACCREDITATION |
This is to certify that |
................................................................................................. |
is ACCREDITED by the |
National Health Insurance Management Authority of Zambia |
To provide insured health care services in |
............................................................ |
Dated this ........ day of ........, 20.. |
Accreditation No.: ................. |
................ |
Conditions of accreditation see overleaf. |
[Reverse side] |
Attached conditions |
(a) This accreditation certificate is not transferrable. |
(b) The accredited health care provider shall adhere to- |
(i) the provisions in the Act and these Regulations; |
(ii) the reporting requirements of insured health care services; |
(iii) national quality assurance systems set by the Authority or other relevant regulatory institutions. |
(c) In the event that the accreditation certificate is revoked, you are expected to surrender this certificate to the Authority. |
Form VIII
[Regulation 11(3)]
THE NATIONAL HEALTH INSURANCE MANAGEMENT AUTHORITY |
The National Health Insurance Act, 2018 |
The National Health Insurance (General) Regulations, 2019 |
NOTICE OF REJECTION OF APPLICATION FOR ACCREDITATION |
(1) Here insert the full names and address | To (1) ................................................................................................ |
.......................................................................................................... |
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(2) Here insert allocated No. | IN THE MATTER OF (2) ................................... you are notified that your application for accreditation has been rejected on the following grounds: |
(a) .................................................................................................. |
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(b) .................................................................................................. |
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(c) .................................................................................................. |
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Dated this .......... day of ........................., 20....... |
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.............................................. |
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NOTE: Section 28 of the Act and Regulation 11 of the National Health Insurance (General) Regulations, 2019 govern this matter. Should you wish to challenge this suspension? |
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Please contact as the Authority on the following address: |
Form IX
[Regulation 14(1)]
THE NATIONAL HEALTH INSURANCE MANAGEMENT AUTHORITY |
The National Health Insurance Act, 2018 |
The National Health Insurance (General) Regulations, 2019 |
NOTICE OF INTENTION TO *SUSPEND/REVOKE ACCREDITATION |
1.Here insert the full names and address of holder | To (1) ....................................................................................................... |
................................................................................................................ |
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2. Here insert the NHIMA Accreditation No. | IN THE MATTER OF (2) .................................... you are notified that the Authority intends to *suspend/revoke your accreditation to provide insured health care services under the National Health Insurance Scheme on the following grounds: |
(a) .................................................................................................. |
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(b) .................................................................................................. |
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(c) .................................................................................................. |
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3. Here insert the number of days | Accordingly, you are requested to show cause why your accreditation should not be *suspended/revoked and to take action to remedy the breaches set out in paragraphs ........... (above) within (3) ..... days of receiving this notice. Failure to remedy the said breaches shall result in the *suspension/revocation of your accreditation. |
Dated this ................. day of .................................. 20........ |
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.............................................. |
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NOTE: |
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(a) *Delete as appropriate |
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(a) Section 30 of the Act and regulation 14 of the National Health Insurance (General) Regulations, 2019 govern this matter. Should you wish to challenge this intention, please contact our Offices as follows: |
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Address: |
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..................................... |
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..................................... |
Form X
[Regulation 14(2)]
THE NATIONAL HEALTH INSURANCE MANAGEMENT AUTHORITY |
The National Health Insurance Act, 2018 |
The National Health Insurance (General) Regulations, 2019 |
NOTICE OF *SUSPENSION/REVOCATION OF ACCREDITATION |
1. Here insert the full names and address of holder | To (1) ................................................................................................ |
......................................................................................................... |
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2. Here insert the NHIMA Accreditation No. | IN THE MATTER OF (2) ........................................................ you are notified that your accreditation to provide insured health care services has been *suspended/revoked on the following grounds: |
(a) .................................................................................................. |
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(b) .................................................................................................. |
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(c) .................................................................................................. |
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Dated this .................. day of .................................. 20............... |
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.............................................. |
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Form XI
[Regulation 16(1)]
THE NATIONAL HEALTH INSURANCE MANAGEMENT AUTHORITY |
The National Health Insurance Act, 2018 |
The National Health Insurance (General) Regulations, 2019 |
HEALTH CARE PROVIDER PAYMENT CLAIM |
Form XII
[Regulation 20]
THE NATIONAL HEALTH INSURANCE MANAGEMENT AUTHORITY |
The National Health Insurance Act, 2018 |
The National Health Insurance (General) Regulations, 2019 |
REGISTER |
1. Contributing Member |
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S/N | Full name | NRC | Membership ID | Date of birth | Sex | Marital status | Physical address | Contact details | Number of dependants | Nationality | Date of first enrolment | Occupational status | ||
Phone No. | ||||||||||||||
2. Accredited Health Care Providers |
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S/N | Provider name | Service type | Physical address | Type of facility (Government, private or faith based and others | NHIMA Accreditation Number | Date of accreditation | Contact details | ||
Phone | |||||||||
3. Employers |
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S/N | Business or company name | NHIMA Identification Number | Employer type | Physical address | Date of registration | Number of employees | Contact details | ||
Phone | |||||||||
4. Pension Scheme |
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S/N | Name of pension scheme | NHIMA Identification Number | Physical Address | Date of registration | Number of pensioners | Contact person | Contact details | |||
Phone | ||||||||||
1. | ||||||||||
2. |
5. Self Employed Ciitizens or Established Residents |
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S/N | Full name | Sector | NRC | NHIMA Identification Number | Date of Birth | Sex | Marital status | Physical Address | Contact details | Number of dependants | Nationality | Date of first enrolment | Current membership status | |||
Phone | ||||||||||||||||
1. | ||||||||||||||||
2. |
Form XIII
[Regulation 21]
THE NATIONAL HEALTH INSURANCE MANAGEMENT AUTHORITY |
The National Health Insurance Act, 2018 |
The National Health Insurance (General) Regulations, 2019 |
NOTICE OF COMPLAINT |
IN THE MATTER OF ............................ |
(Application reference and matter of appeal) I give notice of complaint against the decision of the Authority/Health Complaints Committee due to the following reasons: |
(a) ......................................... |
(b) ........................................... |
(c) .................................. |
(d) ......................................... |
(e) .................................. |
Dated this ......... day of ........ 20.. |
.................... |
Note: Attach brief if necessary. |
[Regulations 4, 6, 11 and 22]
PRESCRIBED FEES
1. Membership | Fee Units |
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Membership Card | Initial | Replacement |
Not Applicable | 100.00 |
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2. Accreditation of health care providers | ||
Category | Fee Units |
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Hospital | 40,000 |
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Hospice | 40,000 |
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Clinic | 20,000 |
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Laboratory, Diagnostic Centre and Pharmacy | 20,000 |
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Ambulance Service | 20,000 |
[Regulations 9 and 10(2)]
CONTRIBUTION RATES
No. | Category | Payment Mechanism | Rate | Frequency | Deadline |
1. | Employee | Payroll based | 1% of basic salary | Monthly | 10th of the following month |
2. | Employer | Payroll based | 1% of basic salary | Monthly | 10th of the following month |
3. | Self-employed | Direct payment | 1% of declared income | Monthly | 10th of the following month |
[Regulation 10(1)]
BENEFIT PACKAGE
The National Health Insurance Benefit Package includes the following- |
1. Medical Care: |
1.1. Consultations, examinations |
1.2. Diagnostic services (Radiology and laboratory) |
1.3. Nursing Care |
1.4. Hospitalisation |
1.5. Intensive Care Unit |
2. Surgery: |
2.1. General Surgery |
2.2. Anaesthetics |
2.3. Orthopaedics |
2.4. Paediatric Surgery |
2.5. Ear, Nose and Throat |
3. Maternity and Neonatal Care: |
3.1. Antenatal Care |
3.2. Delivery (Normal or Assisted) |
3.3. Caesarean Section |
3.4. Postnatal Care |
4. Eye Care Services: |
4.1. Selected services |
5. Oral Health Services: |
Selected services |
6. Pharmaceutical Drugs and Supplies: |
6.1. Prescription generic drugs on the essential drugs list prescribed by an accredited heath care provider an approved or used under the Scheme |
6.2. Medical supplies |
6.3. Blood products |
7. Physiotherapy: |
7.1. Selected services |
The National Health Insurance Benefit Package shall not include- |
1. Treatment abroad |
2. Cosmetic surgery and aesthetic treatments (except reconstructive surgery which it is medically required) |
3. Weight loss procedures and treatment |
4. Long-term inpatient nursing care (over 90 days) |
5. Medical treatment of motor vehicle accident injuries covered by other insurance/funds arrangements, such as motor vehicle insurance and a Motor Vehicle Accident Fund. |
6. Treatment of occupational accidents and illness covered by Worker's Compensation Fund. |
7. Treatment of injuries resulting from declared national disasters in collaboration with the National Disaster Management and Mitigation Unit. |
8. Fertility treatment according to set criteria. |
[Regulation 15]
BENEFIT PACKAGE
S/N | Category | Frequency | Deadline |
1. | Statistical data on members enrolled with the health care provider | Quarterly | 10th day after the end of the quarter |
2. | The insured health care services provided during the reporting period and the conditions under which the services were provided | Quarterly | 10th day after the end of the quarter |
3. | The number and skills of staff of the health care provider | Annually (January to December) | 31st January of the following the reporting period |
4. | The type and state of equipment and infrastructure of the health care provider | Annually (January to December) | 31st January of the year following the reporting period |
5. | The inventory of medicines including stock levels available | Quarterly | 10th day after the end of the quarter |
6. | The relationship with other accredited health care providers and the details thereof | Annually (January to December) | 31st January of the year following the reporting period |
7. | Administrative, financial or medical information relevant to the provision of quality insured health care services | Annually (January to December) | 31st January of the year following the reporting period |