A Health Maintenance Organization is a limited liability company that combines the principles of insurance and healthcare management to provide comprehensive, qualitative, affordable, defined and easily accessible healthcare to an enrolled population through an associated network of healthcare providers who are responsible for care delivery.
An individual or institution that provides medical services (e.g. a physician, hospital, laboratory, e.t.c.)
A healthcare professional responsible for providing a wide variety of basic healthcare services. This is usually the entry point into the healthcare system. The PCP has an on-going relationship with the individual and knows the patient’s medical history; and therefore is responsible for the coordination of the care of the enrollee.
A person who is covered by health insurance.
– Guaranteed access to quality healthcare services
– Better and wider choice of primary care services
– User-friendly healthcare provider network
– Efficient referral system through primary to secondary to tertiary levels of care
– Portability for emergency or out-of-station care
– No penalty for cost of usage
– Access to counseling on immunization services
– Guaranteed customer service satisfaction
– Peace of mind
The form will be duly processed, which includes the issuance of a policy number and the medical scheme I.D card. Upon issuance of your I.D card you can go to the Primary Care Provider indicated on your form to receive care when the need arises.
Only providers accredited for this scheme can be used. You are expected to choose from this list of providers. It is possible your current doctor’s hospital facility might be on our network already, in which case you should be able to choose him.
No, you are not allowed to use a provider not registered on the scheme, except in the event of a medical emergency.
A medical emergency is defined as a medical condition, which if not attended to promptly can lead to death or permanent physical or mental disability. Therefore, arrangement has been put in place for the enrollee to attend any hospital within our provider network, located around the place of occurrence. However, where a health facility within our network is not available, any other hospital in the immediate vicinity can be used, but, Mediplan is to be informed within 24 hours of admission. Such examples of emergencies include: Road Traffic Accidents, fractures, severe bleeding from any part of the body, high blood pressure leading to irrational talk, dizziness e.t.c.
Yes, you can change your healthcare provider under the following circumstances:
1) Transfer to another location, city or state
2) Dissatisfaction with quality of care delivered by your chosen provider after due investigation by Mediplan
3) Change of enrollee’s place of residence.
In each of the above mentioned case, a formal letter should be written to that effect giving 30 days notice. The change will become effective at the start of a new month following the expiration of the 30 days.
However, where the reason for change bears on dissatisfaction with services rendered, there shall be intervention by our medical personnel after which if the need still arises, the change shall be effected.
In an event that an enrollee took ill while out-of-station he / she can obtain treatment from any healthcare provider on Mediplan network on presentation of his / her Mediplan enrollee identification card. The enrollee or the healthcare provider will need to notify us for an authorization code.
Enrollees are not expected to dictate to the provider the drugs to be prescribed or the mode of treatment. Your provider will give to you the drugs that best suit your medical needs in line with the Essential Drug List for the scheme.
A visit to the dentist qualifies as specialist care. A dentist is a specialist care provider. Others will include Dermatologists, Ophthalmologists, ENT Surgeons, Cardiologists, Paediatricians, and Orthopaedic Surgeons etc. In such cases you will visit your primary care provider who will subsequently give you a referral form to see a specialist. In this case, your primary care provider will refer to a dentist.
There is no financial limit to the care you can receive for covered services. There are no hidden charges, no co-payments and no restrictions on the number of attendances or in-patient admission days, provided the premium for the service type has been paid. There are, however, medical limits for lenses based on plan types.
You can only visit your primary care provider for this scheme. However, in cases of medical emergencies you can visit any other provider on Mediplan network and if none exists near the place of occurrence you can visit any other provider. But, Mediplan must be informed within 24 hours
You will be required to formally apply in writing to mediplan for a replacement of I.D. card, supported with a sworn affidavit. Replacement of lost I.D. card will be at a minimal cost to the enrollee.
Refunds shall not be made for benefits not utilized, this is because the premium paid is actuarially determined and is based on the probability that not all enrollees would be sick at the same time.
Mediplan pools the resources from all subscribers to render healthcare to those who may become ill. Likewise, you will not be surcharged, if you get ill more often than others.
Pre-existing conditions are chronic medical conditions diagnosed/undiagnosed in the past for which the enrollee is on treatment or otherwise, before buying into the health insurance policy. Examples of such conditions are Hypertension (Stroke), Diabetes, Sickle Cell Disease, Asthma, Chronic Liver Disease, Glomerulonephritis (chronic renal failure), Congestive Heart Failure, Autoimmune Diseases, etc.