FREQUENTLY ASKED QUESTIONS

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 counselling 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.  

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, SHTL 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.

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.

Refer to the benefit package at SHTL HMO help-desk or with your HR.

Please, present your SHTL HMO ID card or dependant’s at the front desk office to see the doctor.

You will write for a replacement after payment of #500:00, through your HR.

The HMO ID card issued by SHTL simplifies access to medical service at the hospital. It must always be presented by enrolees before treatment as it protects the Provider against impersonation. It is advisable to choose only one hospital for the family, if they are together or specific hospitals for each member of the family if he/she is in a different location. However any enrolee can use ANY Hospital on our Network of Providers in cases of emergency without necessarily being registered there.

You will need to fill a “new inclusion” form, you can obtain the form from the HR. (new entrant must be received by the 17th day of the month otherwise; action may be delayed by a month)

No, unregistered persons cannot replace as Health insurance is not transferable, so ID card is not transferable. The policy covers only the card holder for the chosen healthcare benefits. This is because the healthcare provider is prepaid only for the card holder and has the pictures of all the beneficiaries in his hospital. Only those dependants registered with your employer or for whom you have paid can have access to the scheme with their respective healthcare card. You can take individual policies for them with prorated premiums for your relations to enjoy the scheme.

Any member of the family outside the allowable number of dependants can be registered as “extra dependant” by paying from your pocket on a prorated basis. This is cheaper than out of pocket expenditure.

You will pick a provider from the list of network of providers as your primary care provider.

No not all hospital can, there are primary Providers that attend to primary sickness that do not require a specialist attention. When a specialist attention is needed you will be referred to the specialist within your zone or within the hospital on fee for service.

Such hospitals if not already listed on SHTL HMO provider network shall be inspected and listed, provided the hospital meets 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 enrollee.

There is provision on the registration form for alternate primary provider in the case of participants that live apart from their families. (You and your dependents can each have a different primary care provider).

Enrolees requiring referral to secondary facilities within covered services are referred automatically within the facility; where the facility falls outside the primary provider’s zone, a pre-authorization is obtained from the call centre and the appointment fixed. This is waived in emergencies and paediatrician consults.

No you can’t, because of the mode of payment. You are allowed to visit only one hospital at a time. You reserve the right to change hospital any time, if you are not satisfied with the service provided, or when you change location.
Change can only become effective on the first day of each month when the new hospital chosen would have been adequately notified. Any request for a change or new entrant must be received by the 17th day of the month otherwise; action may be delayed by a month.

You will have to fill a change of hospital form domiciled in the HR department. (Change can only become effective on the first day of each month when the new hospital chosen would have been adequately notified. Any request for a change or new entrant must be received on or before 10th of the month otherwise; action may be delayed by a month).

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.

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

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.

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 enrolees would be sick at the same time.

SHTL 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.

No you can’t request for drugs, your doctor will prescribe drugs based on his clinical findings and judgment.

You can lodge complaints with the client service person(s) assigned to you organization, call our 24hrs call centre numbers to act instantly at point of disaffection, send us an email, or write a letter and send to our office. Nevertheless if you are still not satisfied you can change

Please be informed that you are not to make any payment for a benefit covered under your scheme. Please call SHTL HMO help desk immediately
(Except if you ask for extra favours).
Please inform our call centre at once – 08079393631, 08079393632

Yes, if you are on a corporate plan you are covered immediately. However, on all other individual plans, a 1 year waiting period applies before you are able to access any maternity care benefits

Every enrolee is expected to sign a completed form at the hospital after accessing medical care, for each visit to the Provider. It is very important for quality control.