Q: Are there different types
of plans at Zenith Assurance Medicare
(HMO)?
A: Yes, there are different types of plans:
ZENITH InstantHealth – Individual plan ONLY
ZENITH SmartHealth [plus]
ZENITH ClassicHealth [plus]
ZENITH SuperHealth [plus]
ZENITH ZenithHealth [plus]
ZENITH FlexiHealth –Group plan ONLY
ZENITH HealthManager – “
“
With regard to Corporate Healthcare
Plans, we have Deluxe [for Executive
management staff], Super [for Senior/
Middle management staff], Classic/ Smart
[for other levels of staff]. Basically,
the health coverage in these plans have
a standard coverage of care; differences
exist in admission benefits and a few
other areas;
With the Individual /Family Private
Policy Plans of Zenith Assurance
Medicare (HMO), as illustrated on
the table of benefits for the various
plans. Treatment limits exist according
to type of plan.
Q: Does an enrollee need
an ID card for every member of his/her
family?
A:
Yes;
Enrollees will receive an ID card when
they enroll in Zenith Assurance Medicare plans. The card identifies plan
members and ID card of the Principal
insured suffices for all dependants
under the age of thirteen [13] years; those above 13years will be provided
individual cards;
Although enrollee biodata is forwarded
to the service provider up front as
a scanned document, enrollees must be
asked to show their ID cards each time
they visit the provider;
Q: Does an enrollee need prior authorization
before he/ she can access medical services?
A: No, not at all.
He/ she can walk into his/her chosen
hospital in the Provider network without
notice and receive medical attention
In an emergency, he/she may use any
hospital on the network, using their
ID card; the hospital only notifies
the HMO [Zenith Assurance Medicare] within 48-hours of setting off
the medical care process.
Q: Does an enrollee need to first
contact his/her GP before accessing
after- hours and emergency care?
A: No.
The mission of Zenith Assurance Medicare is to ensure that the patient gets
well as soon as is medically possible
Therefore, all that the doctor on call
has to do is to notify us after setting
all apparatus in motion to address the
immediate health care needs of the enrollee.
Q: Can an enrollee change doctors
at will, especially where he/ she is
dissatisfied with services offered?
A:
Zenith Assurance Medicare (HMO) chooses its service providers with great
care and due diligence
However, where a patient feels ill-treated,
he/she can without let or hindrance
switch doctors
All that needs to be done is to notify
us in writing by completing and dispatching
the relevant form.
Q: Does the HMO encourage its service
providers to reduce, ration or limit
care in order to minimize the cost of
services delivered?
A: No;
Medical doctors abide by their Physicians
oath to provide effective medical aid
without let or hindrance;
The Capitation paid to the service providers
by Zenith Assurance Medicare reasonably
remunerates the efforts of the doctors;
Therefore, the uppermost consideration
on their minds should be the health
of the patient and they do not encourage
compromising the patient’s health.
Zenith Assurance Medicare will make additional fee-for-service
payments where appropriate.
Q: Do I need advance approval as
a General Practitioner to hospitalize
an enrollee?
A: No, not at all;
It is left to the professional judgment
of the doctor to determine the suitability
of hospitalization. His opinion takes
precedence and therefore no prior authorization
is required;
The GP must however notify Zenith
Assurance Medicare (HMO) of the
event.
Q: Is there a limit to an enrollee’s
length of stay in the event of hospitalization?
A:
With regards to our Corporate Policies, there is no time/financial limit i.e.DeluxePlus, SuperPlus,
ClassicPlus and SmartPlus
However, there is time/financial
limit with our Individual/ Family
Private Policy Plans; the annual number
of days on admission is commensurate
with the respective policies as highlighted
in the table of benefits.
Q: If an enrollee has an ailment
that poses a diagnostic challenge, will Zenith Assurance Medicare cover
the medical services rendered without
any objection as to its experimental
nature?
A: Yes, absolutely
However, evidence must be submitted
by the doctor to prove the relevance
of all such investigations carried out
to merit payment.
Q: As a GP, can I refuse an enrollee
a referral which he/she believes is
needed?
A:
Zenith Assurance Medicare respects the opinion of its doctors
and will therefore stand by them;
However, a second opinion could be sought
within the provider network at no extra
cost to the GP;
If there is a confirmation of the earlier
refusal, the decision will be binding
on the patient;
Zenith Assurance Medicare should be kept informed of the outcome
to enable us educate the enrollee on
the decision taken by the GP.
Q: Can I as a service provider refuse
to attend to an enrollee’s medical needs?
A: No, you cannot;
As long as the presenting complaint
is covered under the scheme, and the
enrollee’s Capitation has been paid(
where Capitation applies), or an indication
has been given in writing that we shall
deal on Fee-for-Service with you (where
Capitation does not apply);
In the strictest sense of the word,
the doctors must answer to the needs
of every patient whose capitation
has been paid. Capitation is the key
determinant of whether our patient gets
medical attention or not;
However, if the enrollee presents with
what forms part of the exclusion list
or with a relation who is not duly registered
on the scheme, the doctor has every
right to refuse attention to such errant
enrollees, and also inform Zenith
Assurance Medicare.
Q: Does Zenith Assurance Medicare plans allow the use of branded drugs
for its enrollees?
A: Yes it does;
Generic and Branded drugs are all included;
However, where there is a very good
alternative to a branded drug for a
particular condition, it is advisable
to use the generic drug for economic
reasons.
Q: Does Zenith Assurance Medicare plans cover pre-natal and post-natal
care?
A: Yes it does;
This is on a Fee-for-Service basis;
Cover also includes immunization for
the newborn.
Q: Does Zenith Assurance Medicare plans cover eye glasses, hearing
aids, dentures, cosmetic surgery etc?
A: No, it does not;
Please refer to your benefit package
for Inclusions and Exclusions from the Zenith Assurance Medicare Health
Plans;
However, where a set of enrollees have
their cover extended to include any
of these exclusions, Zenith Assurance
Medicare will keep you posted of
such development in writing.
Q: Does Zenith Assurance Medicare cover needs such as hypertensive
care or pre-existing conditions?
A: Yes it does;
Our plans take into cognizance the nature
of work that corporate enrollees engage
in;
In individual plans, a pre-enrollment
medical examination is required to compute
premium for those with chronic/pre-existing
conditions.
Q: Are there limits on the type of
drugs that doctors can prescribe and
give to patients?
A: Yes, there are;
There are limitations for example, Hormonal
Drugs for Infertility Management (see
exclusion list);
Expensive drugs used for Primary conditions
are paid for separately [Fee-for-service];
To facilitate the settlement of claims, Zenith Assurance Medicare has
developed in conjunction with care providers,
a standard Drug Reimbursement Tariff
[DRT] structure.
Q: Does Zenith Assurance Medicare plans cover HIV/AIDS treatment?
A: Yes;
Plans and special arrangements are available
for management of the condition in the
Individual plan;
It is readily available as a bonus in
the corporate plans.
FREQUENTLY ASKED QUESTIONS [MEMBERS]
Q: Is the scheme compulsory for corporate
enrollees?
A: The scheme is compulsory, not optional
for corporate enrollees
Q: How do I join the scheme?
A: The requirements for the enrollee to
enjoy the scheme is for him/her to complete
the Enrollee Questionnaire, supply names
and passport photographs of self [and
dependant(s), where applicable], so
that relevant identification materials
can be produced and forwarded to hospitals
of choice and pay the premium of preferred
plan. It takes not less than two (2)
weeks to complete this process therefore
all beneficiaries must comply promptly.
Q: Can new hospitals not yet listed
by the HMO be introduced into the scheme?
A: Yes;
The organization/ individual may introduce
all providers [i.e. Doctors] that they
were previously retaining for possible
inclusion in the provider network;
Such hospitals if not already on Zenith
Assurance Medicare list of providers
shall be inspected and listed, provided
the hospitals meet the minimum required
standard and the management of the hospital
is willing to join the scheme and abide
by the rules guiding our operations.
This is in the interest of all enrollees;
The hospital shall only be used eventually
if not less than twenty [20]
enrollees wish to use to use such a
hospital, except there is no other hospital
already listed in that town by Zenith
Assurance Medicare.
Q: Who chooses the Providers?
A: Every enrollee has the right to choose
any of the hospitals he finds on the
list whether or not the organization/
individual was previously using such
a hospital.
Q: What is the limit of cover per
enrollee?
A:
Each enrollee and his dependants [maximum
of spouse and four children] are entitled
to unlimited medical facilities in the
corporate plans. Where an extra dependant
has been paid for by an enrollee, such
benefits also accrue to that person.
The individual plans have limits according
to each plan;
The age limit for a child-dependant
shall be eighteen (18) or maximum, twenty-four
(24) if still in a Tertiary Institution.
Q: How do I receive treatment when
out of station or in an emergency?
A:
For emergency/out of station conditions
that occur in our service area, access
the closest in-network hospital emergency
facility anywhere in Nigeria, without
the need to make any payment on production
of your Zenith Assurance Medicare ID card, otherwise you may
be denied treatment;
When out of our service area, access
the closest hospital emergency facility.
Enrollee and dependants are eligible
for treatment in any unlisted hospital
on production of member ID card, reimbursement
shall be made on presentation of bills
to Zenith Assurance Medicare and
verification of such bills;
However, some out-of-service-area medical
facilities may require you to pay for
your care at the time it is given. To
arrange for reimbursement, send itemized
bills and proof of payment within
90 days to the Zenith Assurance
Medicare claims address;
You will be responsible for out of area
charges that exceed usual and customary
charges;
If you are admitted to the hospital,
you, a relation or next-of-kin must
notify us within 48 hours. This
is in the best interest of the enrollee.
Follow-up care is arranged through your
GP.
Q: What qualifies as a medical emergency?
A:
A medical emergency is a condition that
manifests itself by acute symptoms of
sufficient severity to lead a prudent
layperson who possesses an average knowledge
of health and medicine to reasonably
conclude that a lack of immediate medical
attention will likely result in any
of the following:
• Serious jeopardy to the person’s health,
or with respect to a pregnant woman,
serious jeopardy to the health of the
woman or her unborn child;
• Serious impairment to the person’s
bodily functions;
• Serious dysfunction of one or more
of the person’s body organs or parts.
Examples of emergency conditions include
but are not limited to loss of consciousness,
severe burns, severe pain, heavy bleeding,
and possible heart attacks.
Q: Does the plan cover maternity
care?
A: The scheme covers the female enrollee
and wives of male enrollees for antenatal
care, child delivery up to four [4]
life birth births and gynaecological
treatment. However, an enrollee that
already has a wife and 4 children cannot
enjoy antenatal and delivery care unless
additional premium is paid.
Q: What happens if I need specialist
care?
A: When specialist care is needed, your
GP refers you to a secondary or tertiary
centre where such facility is available.
Q: Who is responsible for inter hospital
transfer transportation?
A: When the need to transfer to a specialist
centre arises, it is the duty of the
provider and Zenith Assurance Medicare to provide transportation if the
patient is moribund. For fit patients,
he/she bears the cost of movement.
Q: If I incur high medical
bills will my employer surcharge me?
A: No;
Deductions are not made on large bills
against an employee’s name. However,
enrollees should note that abuse of
the managed health care system should
not occur;
The mechanism of the scheme is that
there is no financial limit within one
contract year to encourage genuine visits
to the hospital until you are certified
fit health wise.
Q: Can the provider refuse
me treatment because of past frequent
visits?
A: No except:
Enrollees or dependants will not be
refused access to medical care because
they frequent the hospital, except where
an enrollee goes with a dependant
that is not duly registered on the scheme;
Or, the enrollee asks for treatment
of a condition that falls under our
Exclusion list.
Q: Will the HMO make a refund of
my contribution because I did not visit
any hospital during the year?
A: No;
Because the scheme works on the principle
of pooling of risks, the excess money
to treat individuals does not necessarily
come from the premium contributed on
a particular enrollee. It comes from
other contributors to the scheme, which
even spans beyond the population of
any particular group;
Those who fall ill, use up the funds
contributed by those who do not fall
ill within the year, therefore there
is no refund for non-utilization.
Q: What happens if I have more than
four (4) children?
A:
When children are more than 4, or you
want to include additional dependants
and domestic help who reside with you,
simply inform the Human Resource Department
of your corporation who will tell you
how much you will be surcharged [additional
premium];
Individual plans also attract a surcharge
for extra dependants.
Q: If I do not have up to the maximum
of 4 children, can I substitute?
A: No. You are not allowed to substitute
relations for children. You should simply
pay a prorated premium.
Q: What do I do if dissatisfied with
my provider?
A: Report any dissatisfaction of medical
services by your provider to your company
representative or directly to Zenith
Assurance Medicare.
Q: Can I change my provider
within the year??
A:
Any enrollee reserves the right to change
hospitals/ GPs at the end of the quarter
or when he changes residence, provided
the reasons put forward are tangible
enough where it is for reasons other
than change of residence;
Change can only become effective on
the first day of each month when the
new hospital/ GP chosen will have been
adequately notified. Any request for
a change or new entrant must be received
by the 20th day of the month;
otherwise action may be delayed by a
month.
Q: What is Capitation payment?
A: Capitation is the periodic upfront payment
made to the provider on each registered
enrollee with his hospital whether such
enrollee(s) goes for treatment or not.
Q: Does the amount of Capitation
paid monthly represent the limit of
care I can receive?
A: No;
The monthly Capitation which is paid
to the provider whether the enrollee
visits the hospital or not is for primary
care ONLY and does not represent
the cost of care receivable;
Not all persons paid for go for treatment
every month; therefore, those who do
not go for treatment bear the cost of
those who go.
Q: Does Capitation cover expensive
drugs?
A: No;
Capitation does not cover expensive
drugs even when used for primary care
conditions;
Laboratory investigations, admissions,
specialist treatment, surgeries etc
are also not covered by Capitation.
Q: Is substitution of patient or
enrollee allowed?
A: No. Health Insurance is based on each
individual life, hence substitution IS NOT ALLOWED. It is expected
to be an annual contract.
Q: How many types of Healthcare Plans
are available and how do they differ?
A: There are plans for Individual/
Family and Groups; these
plans vary based on services offered
and premiums paid:
ZENITH InstantHealth – Individual plan ONLY
ZENITH SmartHealth [plus]
ZENITH ClassicHealth [plus]
ZENITH SuperHealth [plus]
ZENITH ZenithHealth [plus]
ZENITH FlexiHealth –Group plan ONLY
ZENITH HealthManager – “
“
