Everything You Need to Know About HMO in Nigeria

Everything You Need to Know About HMO in Nigeria

HMO in Nigeria

The common term health is wealth is really true as it holds. You need to be in good health to build and maintain wealth. However, medical bills are out of the roof, and it may often be difficult for many people to cover these expenses without a significant financial burden. This is where HMO in Nigeria come in.

Luckily, HMOs have sprung up to help ease this financial burden and allow us to take charge of our health.  This article aims to enlighten us on how HMOs help to manage your health expenses and improve you’re your financial well-being. We will take a look at different HMOs available to us and survey rates applicable to the service they provide. 

What is an HMO 

HMO stands for Health Maintenance Organization. It is a type of Health Insurance that provides healthcare delivery to its members. Think of it as an insurance company to which you pay a monthly or yearly premium, after which they will take care of your health bill on a need-by-need basis.  

How do HMOs make money?

Typically, the premium you’d pay will be less than the amount required for your health bill. However, these organizations are able to cover the health bill because they pool funds together, and deduct the expenses (medical costs for their members).

Surplus funds are carefully managed by experienced asset managers and often invested in low-risk, highly liquid financial instruments like government bonds or short-term investments to earn a modest return on funds that are not immediately needed to cover expenses.

To dig deeper into the operations, Health Maintenance Organizations (HMOs) operate as managed care organizations, and their ability to cover healthcare expenses while making a profit relies on a combination of some factors and strategies which include: 

Premiums

HMOs in Nigeria collect premiums from both individual members and organizations (employers). These premiums are a primary source of revenue. HMOs carefully price their plans to ensure that the collected premiums cover the expected healthcare expenses and provide a margin for profit. 

Risk Pooling

HMOs rely on the concept of risk pooling, where they enroll a diverse group of individuals and organizations. Not everyone in the pool will require expensive medical care simultaneously. This diversity allows HMOs to use the premiums from healthier individuals to offset the costs of those who require more healthcare services. 

Provider Networks

HMOs establish contracts with a network of healthcare providers, including hospitals, clinics, and physicians. These providers agree to accept negotiated, lower reimbursement rates in exchange for a consistent stream of patients from the HMO. This cost control enables HMOs to manage expenses effectively. 

Utilization Management

HMOs implement utilization management strategies to control healthcare utilization and costs. These include pre-authorization requirements for certain medical procedures, utilization review, and care coordination to ensure that care is provided efficiently and effectively. 

Primary Care Physicians (PCPs)

The use of PCPs as gatekeepers helps manage costs. PCPs serve as the first point of contact for members, coordinating and authorizing referrals to specialists or hospitalization when necessary. This ensures that care is appropriate and not unnecessarily expensive. 

Preventive Care

HMOs emphasize preventive care and wellness programs to keep members healthy. By proactively addressing health issues and preventing the escalation of chronic conditions, HMOs reduce the need for costly medical interventions in the long run. 

Risk-Based Contracts

Some HMOs enter into risk-based contracts with healthcare providers. In these contracts, providers agree to take on a portion of the financial risk for patient care. If they can manage patient health effectively and keep costs down, they share in the savings, creating incentives for cost-effective care. 

Care Coordination

HMOs invest in care coordination teams that work to ensure that members receive appropriate and cost-effective care. This can include case management for members with complex medical needs. 

Data Analytics

HMOs leverage data analytics to identify trends and opportunities for cost savings. They can use data to identify high-cost areas, track the health of their member population, and identify areas for improvement. 

Government Programs

In some cases, HMOs participate in government programs like Medicaid or Medicare Advantage, where they receive payments from the government to provide healthcare services to eligible individuals. These programs often have strict regulations and oversight but can be profitable if managed effectively.

Why do I need HMO services?

  • Affordability: HMOs usually have lower costs, which can make healthcare more budget-friendly. For instance, I once had a hospital episode where I spent a total of ₦200,000 on hospital bills. However, Axa Mansards’ basic plan would have covered these bills and any other hospital visit I would have had to make after that for just ₦90,000   
  • Predictable Costs: With HMOs, you know exactly what you’ll pay for doctor visits and other services, making budgeting easier. For more context, I know in a year, ₦90,000 is enough to cover my basic health-care needs. 
  • Primary Care Coordination: You’ll choose a primary care doctor who helps manage your healthcare, making sure everything runs smoothly. 
  • Preventive Care: HMOs focus on keeping you healthy with screenings, vaccinations, and health tips. 
  • Less Administrative Hassle: HMOs handle paperwork and claims, so you don’t have to deal with complicated billing. 
  • Network of Providers: They have a set of doctors and hospitals you can choose from. 
  • Specialist Referrals: Your primary doctor will refer you to specialists when needed. 
  • Emergency Coverage: Even in emergencies, you’re covered, even if it’s outside the network. 

How do HMOs work? 

A. Membership and Enrollment 

Individual Enrollment 

When it comes to HMOs, individuals can sign up for coverage. This means you can directly enroll yourself and your family members, which is great for those not covered by employer plans. 

Employer-Sponsored Plans 

Now, if you’re part of an organization, there’s a good chance your employer will offer HMO plans. These are often a part of employee benefits packages. It’s a convenient way for companies to ensure their employees have access to healthcare. 

B. Premiums and Payment 

Every month, you’ll need to pay a premium to maintain your HMO coverage. This is the cost of your healthcare plan. The premiums can vary depending on the plan you choose and your specific circumstances. 

C. Primary Care Physicians (PCPs) 

Role of PCPs 

Your Primary Care Physician (PCP) is like your go-to person for all of your healthcare needs. They’re your first point of contact for all things health-related. Whether it’s a general check-up, a health concern, or a referral to a specialist, your PCP is the go-to person. 

PCP Selection 

You’ll have the freedom to choose your PCP from a list provided by the HMO. This is a critical decision since your PCP plays a central role in your healthcare journey. Take your time to pick someone you trust and feel comfortable with. 

D. Provider Networks

Healthcare Providers within HMO Networks 

HMOs have a network of healthcare providers, which includes doctors, specialists, hospitals, and clinics. These providers have contracts with the HMO, agreeing to offer services to HMO members at negotiated rates. 

In-Network vs. Out-of-Network Care 

It’s important to note that your HMO typically covers the costs of care received within its network. This means you’ll have lower out-of-pocket expenses when you see in-network providers. If you choose to go out of network for care, your coverage might be limited or not covered at all, except in emergencies. 

Are HMOs only available to employees?

HMOs (Health Maintenance Organizations) are not exclusively available to employees. While many employers offer HMO plans as part of their employee benefits packages, HMOs are available to a broader range of individuals, including: 

  • HMO for Individuals and Families: HMO plans are available for anyone, whether you’re working or not. You can enroll yourself and your family directly in these plans. 
  • HMO for Self-Employed Individuals: If you’re self-employed, a freelancer, or have your own business, you can opt for an HMO plan to secure healthcare coverage for yourself. 
  • HMO for Small Business Owners: Small business owners can offer HMO plans to their employees, but they can also choose to enroll themselves in these plans for personal healthcare coverage. 
  • Retirees: When you retire and no longer have access to your employer’s health insurance, you can consider HMO plans designed for retirees to continue their healthcare coverage. 
  • HMO for Students: There are specific HMO plans tailored to students, whether you’re in the university or pursuing education at a younger age. 
  • General Population: HMOs are generally open to everyone, regardless of employment status. You can directly contact HMO providers or seek assistance from insurance professionals to find the most suitable plan for your healthcare needs. 

What are the various HMOs available to Nigerians? 

Each HMO has its unique features and benefits, but here are some common HMO services in Nigeria and their associated benefits: 

Hygeia HMO

HMO in Nigeria - Hygeia HMO
  • A comprehensive network of healthcare providers. 
  • Access to a wide range of hospitals, clinics, and specialists. 
  • Emphasis on preventive care and wellness programs. 
  • Electronic medical records for better coordination of care. 
  • Easy claims processing and reimbursement. 

Plans and rates 

Personal/ Individual plans  
Plan Name Plan Terms Pricing  
Hybasic Plan Inpatient Limit- ₦350,000 Monthly Price: ₦5,450.00 
 Outpatient Limit -₦100,000 Annual Price:  ₦55,590.00 
 Please Click Here For More Coverage Terms  
Hyprime Plan Inpatient Limit (₦) 500,000 Monthly Price: ₦16,370.00 
 Outpatient Limit (₦) 200,000 Annual Price: ₦166,974.00  
 Please Click Here For More Coverage Terms  
Hyprime Plus Plan Inpatient Limit (₦) 600,000 Monthly Price: ₦44,010.00 
 Outpatient Limit (₦) 300,000 Annual Price: ₦448,902.00 
 Please Click Here For More Coverage Terms  
Family Plans   
Hybasic Family Of (4) Plan Inpatient Limit (₦) 350,000 Monthly Price: ₦22,560.00 
 Outpatient Limit (₦) 100,000 Annual Price: ₦230,112.0 
 Please Click Here For More Coverage Terms  
Hyprime Family Of (4) Plan Inpatient Limit (₦) 500,000 Monthly Price: ₦65,450.00 
 Outpatient Limit (₦) 200,000 Annual Price: ₦667,590.00 
 Please Click Here For More Terms  
Small Business Plans   
Hystarter Plan Inpatient Limit (₦) 450,000 Monthly Price: (₦)4,980.00 
 Outpatient Limit (₦) 250,000 Annual Price: (₦)50,796.00  
 Please Click Here For More Coverage Terms  
Hystarter Premium Plan Inpatient Limit (₦) 600,000 Monthly Price: (₦)27,480.00 
 Outpatient Limit (₦) 300,000 Annual Price: (₦)280,296.00 
 Please Click Here For More Coverage Terms  
Corporate Plans   
Hydeal  Get A Quote 
Hylite  Get A Quote 
Hybrid  Get A Quote 

Reliance HMO

HMO in Nigeria - Reliance HMO
  • Affordable healthcare plans with various coverage options
  • Extensive network of healthcare facilities
  • Telemedicine services for remote consultations
  • Health education and wellness initiatives
  • Access to top-quality hospitals and specialists

Plans and rates 

Family/ Individual plans   
Plan Name Plan Terms Pricing  
Red Beryl Plan Spending limit- ₦1,200,000 Monthly Price:₦3500/per individual 
   
Alexandrite Plan Spendinglimit- ₦1,800,000 Monthly Price:₦6000/per individual 
   
Diamond Plan Spending limit- ₦3000,000 MonthlyPrice:₦13,500/per individual 
   
Small Business/Corporate Plans  Get a quote 

Total Health Trust (THT) HMO

HMO in Nigeria - Total Health Trust THT HMO
  • Robust provider network across Nigeria
  • Wellness programs and health assessments
  • Dedicated customer support
  • Preventive care and health promotion

Plans and rates

Specialized plans for different demographics, including individuals, families, and corporate organizations. THT also provides HMO services across locations, and their plans are not fixed but are rather negotiated.

Avon HMO

HMO in Nigeria - Avon HMO
  • Extensive network of hospitals and clinics
  • Customizable healthcare plans
  • Wellness programs and health screenings
  • 24/7 customer service
  • Electronic health records for better care coordination

Plans and rates

Retail plans  
Plan Name Pricing  
Lifestarter ₦27,500 
Life plus ₦49,500 
Premium life ₦76,999 
Boss life  ₦159,099 
Small Business/Corporate plans Get a quote 

AXA Mansard HMO

HMO in Nigeria - AXA Mansard HMO
  • Affordable healthcare options
  • Access to a network of healthcare providers
  • Preventive care and health promotion
  • Prompt claims processing
  • Telemedicine services for convenient consultations

Plans and rates

Retail plans   
Plan Name Plan Terms Pricing  
BRONZE PLAN Inpatient limit- ₦350,000 Annual Price: ₦58,446 
 Outpatient limit- ₦150,000  
 Please click here for more coverage terms  
SILVER PLAN Inpatient limit- ₦500,000 Annual Price: ₦78,359 
 Outpatient limit- ₦250,000  
 Please click here for more coverage terms  
GOLD PLAN Inpatient limit- ₦1000,000 Annual Price: ₦171,076 
 Outpatient limit- ₦300,000  
 Please click here for more coverage terms  
   
Small Business/Corporate plans  Get a quote 

The Bottom Line?

In a nutshell, HMOs are open to everyone, job or no job. Whether you’re self-employed, running a small business, studying, or enjoying retirement, HMOs have plans to suit your needs. All you have to do is explore your options, find what matches your situation, and you’re all set! 

For Individuals and Families, HMOs offer healthcare plans that you can sign up for directly, whether you’re working or not. This means you, your family, and anyone looking for reliable healthcare coverage can enroll without any employment-related restrictions. 

Self-Employed or Freelancers: If you’re your own boss, working as a freelancer, or have your own business venture, HMO plans are readily available for you. You can secure healthcare coverage tailored to your specific needs, ensuring you have access to medical care when you need it. 

Small Business Owners: Small business owners have the option to provide HMO plans to their employees, but they can also choose to enroll themselves and their families in these plans. It’s a flexible approach that allows business owners to prioritize their own healthcare needs. 

Retirees: Retirement doesn’t mean you lose access to quality healthcare. HMOs offer plans designed specifically for retirees, ensuring that you can continue to enjoy comprehensive healthcare coverage during your retirement years. 

Open to All: The beauty of HMOs is that they’re generally open to everyone, regardless of your current employment status. You can reach out directly to HMO providers or seek assistance from insurance experts to find the perfect plan that aligns with your specific healthcare requirements and financial circumstances.

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