The National Health Insurance Bill, No. 22 of 2017

1 22, 20176th December, 2017 THE National Health Insurance Bill, 2017 MEMORANDUMThe objects of this bill are to (a)provide for sound financing for the National Health system;(b)provide for a universal access toqualityinsured healthcare services;(c)establish the National Health Insurance ManagementAuthority and provide for its functions and powers;(d)establish the National Health Insurance Scheme andprovide for its systems, procedures and operation;(e)establish the National Health Insurance Fund and providefor contributions to and payment from the Fund;(f)provide for accreditation criteria and conditions in respectof insured Health care services;(g)provide for complaints and appeals processes;(h)provide for the progressive establishment of provincialand district Health offices of the Authority; and(i)provide for matters connected with, or incidental to, MWANSA, 22, 2017 THE National Health Insurance Bill, 2017 ARRANGEMENTOFSECTIONSPART title and and power of exemptionPART of National Health Insurance of of of of and other staff of and district offices of AuthorityPART IIINATIONALHEALTHINSURANCE, of National Health Insurance Scheme13.

2 Membership and of travel Health Insurance by and payment exempt from unit fees and charges and payment Membership of member s of of on change of membership status24. ModificationsNational Health Insurance [No. of 2017 22, 2017 PART IVACCREDITATIONOFHEALTHFACILITIES26. Prohibition of provision of insured Health care services for accreditation to provide insured Health or rejection of application for with or revocation of of accredited Health care requirements for accredited Health care for insured Health care patient record system and provider s enrolment with accredited Health care to provide insured Health care servicesPART with quality and monitoring of National Health Insurance and management of accounts and reportPART of and report4 No.]

3 Of 2017] National Health InsurancePART Complaints Committee and from execution of in lieu of by body penalty57. RegulationsSCHEDULEN ational Health Insurance [No. of 2017 22, 2017A BILLENTITLEDAn Act to provide for sound financing for the National healthsystem; provide for a universal access to quality insuredhealth care services; establish the National HealthInsurance Management Authority and provide for itsfunctions and powers; establish the National HealthInsurance Scheme and provide for its systems, proceduresand operation; establish the National Health InsuranceFund and provide for contributions to and payments fromthe Fund; provide for accreditation criteria and conditionsin respect of insured Health care services; provide forcomplaints and appeals processes; provide f or theprogressive establishment of provincial and district healthoffices of the Authority.

4 And provide for matters connectedwith, or incidental to, the by the Parliament of Act may be cited as the National Health InsuranceAct, 2017, and shall come into operation on the date appointed bythe Minister by statutory this Act, unless the context otherwise requires accreditation means the process of recognition of a healthcare provider as one that is allowed to provide insuredhealth care services for the purposes of this Act; accredited Health care provider means a Health careprovider that is accredited by the Authority under section28; actuarial assessment means the periodic valuation of aScheme, made in accordance with actuarial methods; National Health Insurance [No. of 2017 7 EnactmentShort 22, 201751015 admission means a procedure where a person isaccommodated overnight or for such other prescribedperiod by a Health care provider for the purposes ofreceiving necessary in-patient services and admitted and cognate expressions shall be construed accordingly; Authority means the National Health InsuranceManagement Authority established under section 4; bank has the meaning assigned to the word in the Bankingand Financial Services Act, 2017.]

5 Benefit means a direct insured Health care service in theform of treatment or an indirect insured Health care serviceconsisting of a reimbursement of the expenses borne by amember and provided by an accredited Health care providerand may include authorised tertiary Health care servicesor a cash benefit; benefit package means the benefits a member is entitledto under the Scheme; billing means making a claim by an accredited Health careprovider for insured Health care service expenses; Board means the Board of the Authority constituted undersection 6; casual employee has the meaning assigned to the wordsin the Employment Act; Chairperson means the Chairperson of the Board,appointed under section 6; child has the meaning assigned to the word in theConstitution; citizen has the meaning assigned to the word in theConstitution; committee means a committee of the Board constitutedunder section 8; Council means the Health Professions Council establishedunder the Health Professions Act, 2009; dependant means a person, who resides with a member,and relies on the member s income for survival.

6 Emergency medical condition means the sudden, and atthe time unexpected onset of a Health condition that requiresimmediate medical or surgical treatment, where failure toprovide medical or surgical treatment would result in seriousimpairment to bodily functions or serious dysfunction of abody organ or part or would place the person s life in seriousjeopardy;Act No. 7of 20178 No. of 2017] National Health InsuranceCap. 268 Cap. 1 Cap. 1 Act No. 24of 22, 2017510152025303540 employee has the meaning assigned to the word in theEmployment Act; employer has the meaning assigned to the word in theEmployment Act; established resident has the meaning assigned to the wordin the Immigration and Deportation Act, 2010; family member means a registered child, spouse anddependant of a member; Fund means the National Health Insurance Fundestablished under section 41; Health care expense means an amount payable in respectof an insured Health care service provided to a member byan accredited Health care provider; Health care provider includes an institution or agency thatprovides Health care services.

7 Health care service has the meaning assigned to the wordunder the Health Professions Act, 2009; Health Insurance number means an identification number,assigned to a member by the Authority and stated on amember s membership card; member s membership card; Health practitioner has the meaning assigned to the wordsunder the Health Professions Act, 2009; inpatient service means a Health care service provided bya patient who is admitted overnight by a Health careprovider; inspector means a person appointed as an inspector undersection 40; insured Health care service means a Health care serviceavailable under the Scheme; medical doctor means a Health practitioner registered assuch under the Health Professions Act, 2009; member means a member of the Scheme as providedunder section 13; member contribution means such amount as may beprescribed for purposes of section 15; membership card means a card issued to a person registeredunder the Scheme; out patient service means a Health care service or procedureprovided by a Health care provider to a patient who is notadmitted by a Health careprovider; National Health Insurance [No.]

8 Of 2017 9 Cap. 268 Cap. 268 Act No. 18of 2010 Act No. 24of 2009 Act No. 24of 2009 Act No. 24of 22, 2017510152025303540 patient means a member who is receiving or has receivedtreatment from an accredited Health care provider; pension scheme means a pension scheme established underany other law; private Health insurer means a company that provides healthinsurance; provider payment system means the manner of payment toa Health care provider for delivery of Health services tomembers; Scheme means the National Health Insurance Schemeestablished under section 12; treatment means medical, surgical, obstetric or dentaltreatment or such other medical treatment as may beprescribed; and Vice-Chairperson means the Vice-Chairperson of the Boardelected under section (1) The provisions of this Act shall bind the Republic.

9 (2)The Minister may prescribe Health care services that arenot covered by the Scheme.(3)The Minister by statutory instrument may extend thecategories of individuals to whom this Act IITHENATIONALHEALTHINSURANCEMANAGEMENTAU THORITY4.(1) There is established the National Health InsuranceManagement Authority which is a body corporate with perpetualsuccession and a common seal, capable of suing and being sued inits corporate name and with power, subject to this Act, to do allacts and things that a body corporate may, by law, do or perform.(2)The Schedule applies to the functions of the Authority are to (a)implement, operate and manage the Scheme;(b)manage the Fund;(c)accredit Health care providers;(d)develop a comprehensive benefit package to be accessedby members;(e)register and issue membership cards to members;(f)facilitate (i) access by poor and vulnerable people to insuredhealth care services; and10 No.

10 Of 2017] National Health InsuranceApplicationand powerof exemptionEstablishmentofNationalHealthIn suranceManagementAuthorityFunctions 22, 20175101520253035(ii) protection of the indigent againstdeprivation ofhealth services;(g)receive, process and pay claims for services rendered byaccredited Health care providers;(h)undertake public education and awareness programmeson Health Insurance ;(i)undertake research in Health Insurance to inform policyformulation and implementation;(j)advise the Minister on Health Insurance and Health insurancepolicy formulation;(k)undertake programmes that further the sustainability ofthe Scheme;(l)develop guidelines, processes and manuals for the effectiveimplementation and management of the Scheme;(m)ensure that an accredited Health care provider deliversefficient and quality insured Health care services;(n)monitor and ensure compliance with this Act and guidelines,policies, processes and manuals made by the Authorityin the performance of its functions under this Act;(o)undertake, in collaboration with relevant regulatoryagencies inspection of Health facilities operated byaccredited Health care providers;(p)receive, investigate and determine complaints by membersand accredited Health care providers in accordance withsection 49;(q)collaborate with corresponding Health insurancemanagement authorities in other countries.