HMO Controversy: What Nigerians, hospitals need to know about health insurance

A viral social media post about the use of Health Maintenance Organisations (HMOs) has sparked controversy among Nigerians and healthcare professionals over health insurance.

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The post, made on X on 2 August by user @106_36_52, who identifies as a medical doctor on the platform, criticised a family who, according to him, visited a hospital after church for medical checks under their HMO plan.

“I give the federal government 24 hours to ban this thing called HMO in Nigeria. Full family, straight from church with matching Ankara. Third set only today. God abeg,” he wrote.

The post had generated more than 1.9 million views as of 12 August and was subsequently shared by blogs, attracting reactions from Nigerians and healthcare professionals.

While some Nigerians questioned why healthcare providers should be concerned about how frequently insured patients use their health plans, others argued that the reactions failed to recognise the financial and administrative pressures faced by healthcare providers and HMOs.

In this explainer, PREMIUM TIMES examines how health insurance works in Nigeria, the responsibilities of patients, healthcare providers and HMOs, and what the law says about their obligations.

How health insurance works

One of the biggest misconceptions exposed by the debate is the idea that an HMO patient is receiving free treatment.

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The patient may not pay the hospital at the point of service, but that does not mean the service is free or that the provider is working for free.

Health insurance is built around pooling financial contributions to pay for healthcare when members need it. The National Health Insurance Authority (NHIA) describes social health insurance as a system in which contributions are pooled to provide a defined package of healthcare services.

Pelumi Akinboade, a senior executive officer and insurance nurse, explained that HMOs perform important administrative functions within this arrangement, including enrolment, claims management, authorisation, quality assurance and coordination between enrollees and healthcare providers.

He said providers are paid through arrangements such as capitation and fee-for-service, depending on the level and nature of care.

“Patients may not bear the bulk of their care costs out of pocket, as their respective insurance companies pay their healthcare providers directly through capitation and fee-for-service,” Mr Akinboade told PREMIUM TIMES.

A patient using an insurance plan is not asking a doctor to treat them for free. They are accessing a service that is supposed to be financed through an insurance arrangement.

Doctors’ frustration

The viral post, however, also highlights another side of the system. It is easy to dismiss a doctor’s complaint as hostility towards HMO patients.

Healthcare providers depend on HMOs to pay for services they have already provided, and problems with payments or authorisations can affect how facilities deliver care.

Mr Akinboade identified delayed payments, administrative bottlenecks, limited coverage, and disputes between providers and HMOs as factors that can contribute to delays or denials of care.

The NHIA Act 2022 specifically provides penalties for failure to remit payments to healthcare providers within the stipulated period and for failure to settle fee-for-service and other claims within the required timeframe.

The federal government has also acknowledged pressure on provider financing. In announcing revised payment rates under the national health insurance scheme, the NHIA said capitation fees had increased by more than 90 per cent, while fee-for-service payments had risen by 378 per cent.

The Coordinating Minister of Health and Social Welfare, Muhammad Pate, said the adjustment was intended to reduce the financial burden on healthcare providers and improve services for enrollees.

So while a patient’s use of their insurance should not automatically be blamed for a provider’s frustration, neither can the financial concerns of healthcare facilities be dismissed.

The law, dispute

Section 47 of the NHIA Act 2022 provides that disputes among parties under the Act should first be referred to the Authority for mediation and conciliation. The Act specifically identifies HMOs, healthcare providers, contributors, and the Authority as parties that may be involved in such disputes.

Section 48 makes it an offence to fail to remit payments to healthcare providers within the period specified in the operational guidelines, fail to settle fee-for-service or other provider claims within the stipulated period, or fail to provide care to a duly registered enrollee.

These provisions suggest that the law itself recognises the possibility of disputes over payments, claims and access to care within the health insurance system. This means the tension playing out online between patients, healthcare providers and HMOs is not simply a question of patients “overusing” their insurance.

It also raises questions about whether the obligations imposed on each party are being fulfilled.

In other words, while enrollees are expected to understand the terms of their health plans and follow the applicable procedures, healthcare providers and HMOs also have obligations under the regulatory framework governing health insurance in Nigeria.

Insured patients still have rights.

Mr Akinboade said healthcare providers must recognise this distinction. Hospitals, he said, should have trained personnel who understand health insurance and can properly guide patients through the process.

He rejected the idea that insured patients should receive a lower standard of care because they are not paying directly at the point of treatment.

“Insurance patients are not secondary patients. They own the right to quality healthcare services,” he said.

That position is consistent with the NHIA’s own statement of enrollee rights. The Authority says Nigerians covered under its programmes have the right to easy access to quality healthcare without hindrance and to be treated with respect and dignity.

The distinction is particularly important in Nigeria, where health insurance coverage remains low, and households continue to shoulder a large share of healthcare costs.

A 2025 Nigeria Health Systems and Services Profile published through the African Health Observatory Platform, with World Health Organisation (WHO) involvement, reported that out-of-pocket spending accounted for more than 75 per cent of total health expenditure and estimated that only about five per cent of Nigerians were covered by health insurance, prepayment or other risk-pooling mechanisms.

In such a system, health insurance is intended to protect households from the financial consequences of illness.

Patients also have responsibilities.

Mr Akinboade said patients also need to understand the health insurance package they have enrolled in.

Different plans have different benefits, exclusions and limitations. Enrollees therefore need to understand the services covered by their plans, the facilities available to them and the procedures for referrals and authorisations.

Patients should also know how to report problems when care is delayed or denied. Mr Akinboade advised enrollees to keep the contact details of their HMO’s customer service or quality assurance unit and escalate complaints when necessary.

Health insurance, therefore, is not simply a card presented at a hospital. It is an arrangement that creates responsibilities for patients, healthcare providers and HMOs.

What needs to change

Improving the system will require action from all sides, Mr Akinboade said.

He added that HMOs need to process claims and pay healthcare providers promptly while ensuring that referrals and authorisations do not create unnecessary barriers to care.

Healthcare providers need trained insurance desk officers who understand the terms of different plans and can communicate them clearly to patients.

Regulators also need to enforce existing rules and impose consequences where organisations fail to meet their obligations.

Meanwhile, patients need to understand their benefits, exclusions and responsibilities and use available complaint mechanisms when they encounter problems.

The NHIA Act provides a framework for resolving disputes between HMOs, healthcare providers, contributors and the Authority, including mediation and conciliation.