Regulation .za

Supplement to the Republic of Zambia Government

267

Gazette dated Friday, 20th September, 2019

GOVERNMENT OF ZAMBIA

STATUTORY INSTRUMENT NO. 63 OF 2019

The National Health Insurance Act, 2018 (Act No. 2 of 2018)

The National Health Insurance (General) Regulations, 2019

ARRANGEMENT OF REGULATIONS

Regulation 1. Title 2. Interpretation 3. Registration as member 4. Application for health insurance by foreigner 5. Membership Card 6. Replacement of membership card 7. Change of membership status 8. Removal of member from Scheme 9. Contribution rates 10. Benefit packages and payment mechanisms 11. Application for accreditation 12. Criteria for accreditation 13. Display of certificate of accreditation 14. Suspension or revocation of accreditation 15. Reporting requirements for accredited health care provider 16. Payment of claims for insured health care services 17. Confidential patient record system 18. Accredited health care provider payment health system 19. Percentage of monies to be disbursed 20. Register 21. Complaints 22. Fees

Copies of this Statutory Instrument can be obtained from the Government Printer, P.O. Box 30136, 10101, Lusaka, Price K76.00 each

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FIRST SCHEDULE SECOND SCHEDULE THIRD SCHEDULE FOURTH SCHEDULE

FIFTH SCHEDULE

20th September, 2019

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IN EXERCISE of the powers contained in section 57 of the National Health Insurance Act, 2018, the following Regulations are made:

1. These Regulations may be cited as the National Health Title Insurance (General) Regulations, 2019.

2. In these Regulations unless the context otherwise requires-- Interpretation

"benefit package" means the benefit package set out in the Fourth Schedule;

"certificate of accreditation" means a certificate of accreditation issued under regulation 11;

"citizen" has the meaning assigned to the word in the

Constitution;

Cap. 1

"clinic" means a health facility that provides outpatient services and includes a health facility that provides dental and vision care;

"Committee means the Health Complaints Committee of the Board continued under the Act;

"employee" has the meaning assigned to the word in the Employment Code Act, 2019;

"employer" has the meaning assigned to the word in the Employment Code Act, 2019;

"established resident" has the meaning assigned to the word in the Immigration and Deportation Act, 2010;

"hospice" means a place where a person who is terminally ill receives palliative care;

Act No. 3 of 2019 Act No. 3 of 2019

Act No. 18 of 2010

"hospital" means a health facility that provides inpatient and outpatient services;

"member" has the meaning assigned to the word in the Act;

"membership card" means the membership card issued to a member under regulation 5; and

"register" means a register established by the Authority under regulation 18;

"Zambia Medicines Regulatory Authority" means the Zambia

Medicines Regulatory Authority established under the Act No. 3 of

Medicines and Allied Substances Act, 2013.

2013

3. (1) Subject to subregulations (2) and (3), an eligible citizen Registration or established resident shall register as a member of the Scheme in as member

Form I set out in the First Schedule.

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(2) An employer shall register an employee with the Authority as a member in Form I set out in the First Schedule.

(3) A manager of a pension scheme shall register a retiree under that pension scheme as a member in Form I set out in the First Schedule.

Application for health insurance by foreigner

4. A foreigner who enters the Republic without valid health insurance, shall, on arrival in the Republic at the port of entry, apply to a health insurance for health insurance in Form II set out in the First Schedule on payment of a fee determined by the health insurer.

Membership card

5. (1) The Authority shall, within sixty days of receipt of registration in Form I under regulation 3, issue a membership card in Form III set out in the First Schedule.

(2) A member shall, on receipt of the membership card under sub-regulation (1), present the membership card to an accredited health care provider in order to access a benefit package.

Replacement of membership card

6. (1) A member whose membership card is lost, defaced or destroyed shall apply to the Authority for a replacement card in Form IV set out in the First Schedule on payment of the fee set out in the Second Schedule.

(2) The Authority shall, within thirty days of receipt of an application under sub-regulation (1), issue a replacement membership card in Form III set out in the First Schedule.

Change of membership status

7. A member shall inform the Authority of any change in the membership status of that member in Form V set out in the First Schedule.

Removal of

8. A person ceases to be registered as a member under the

member from Scheme

Scheme if that person dies, ceases to be a citizen or established

resident.

Contribution rates

9. An employer or self-employed citizen or established resident shall pay to the Scheme a contribution consisting of the employer's contribution and the employee's contribution at the rates set out in the Third Schedule.

Benefit package and payment mechanisms

10. (1) A member is entitled to the benefit package set out in the Fourth Schedule.

(2) An employer or self-employed citizen or established resident who fails to pay a contribution or remit a contribution of an employee due to the Scheme as set out under sub-regulation (1) commits an offence for the purposes of section 53 of the Act.

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(3) Despite sub-regulation (2), where an employer fails to pay an unremitted contribution owed by an employer due to the Scheme, the unpaid amount shall be a civil debt due to the Scheme and shall be summarily recoverable.

11. (1) Ahealth care provider that wishes to provide an insured health care service to a member shall apply to the Authority for accreditation in Form VI set out in the First Schedule on payment of the fee set out in the Second Schedule.

Application for accreditation

(2) TheAuthority shall, where it approves an application, issue the health care provider with a certificate of accreditation in Form VII set out in the First Schedule.

(3) The Authority shall, where it rejects an application for accreditation, inform the applicant in Form VIII set out in the First Schedule.

12. The Authority shall accredit a health care provider if the Criteria for

health care provider --

accreditation

(a) has the capacity to deliver the insured health care services determined by the Authority; and

(b) passes a physical inspection carried out by the Authority of the facility used by the health care provider.

13. An accredited health care provider shall display the certificate of accreditation in a conspicuous place at the place of practice.

14. (1) The Authority shall, where it intends to suspend or revoke an accredited health care provider's accreditation, notify the accredited health care provider of its intention to suspend or revoke the accreditation in Form IX set out in the First Schedule.

Display of certificate of accreditation

Suspension or revocation of accreditation

(2) TheAuthority shall, notify an accredited health care provider of the suspension or revocation of accreditation in Form X set out in the First Schedule.

15. An accredited health care provider shall provide theAuthority with a report of insured health care services in the format set out in the Fifth Schedule.

Reporting requirements for accredited health care provider

16. (1) An accredited health care provider that provides a Payment of

health care service to a member, shall submit a claim to theAuthority

claims for insured health

in Form XI set out in the First Schedule.

care services

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