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The short answer
NHIA-backed plans generally cover outpatient care, prescribed essential drugs and tests, maternity care, immunisation, specialist referrals and limited hospital stays, while excluding a list of high-cost and chronic treatments. NHIA's FAQ (October 2026) confirms there are full and partial exclusions and that dialysis is limited to six sessions a year, but it does not publish the full current list; your HMO or state scheme must give you your plan's benefit schedule.
Why the list differs by plan
Under the NHIA Act, as KPMG Nigeria summarised in June 2022, state schemes and accredited HMOs deliver cover and NHIA sets operational guidelines. A federal formal-sector plan, a state informal-sector plan and an HMO retail plan can therefore carry different benefit lists. What follows is the standard package NHIS published in its 2005 operational guidelines, which most plans still resemble, plus the points NHIA confirms today. Treat the 2005 lists as a guide to the questions to ask, not as your plan's terms.
What is usually included
The 2005 guidelines listed this formal-sector package:
- Outpatient care, including consultations.
- Prescribed drugs and diagnostic tests on the essential drugs and tests lists.
- Maternity care for up to four live births.
- Preventive care, including immunisation.
- Consultation with specialists on referral.
- Hospital care in a standard ward, capped at 15 cumulative days a year.
- Eye examination and care, but not spectacles or contact lenses.
- Locally made artificial limbs.
- Basic preventive dental care and pain relief.
NHIA's current FAQ adds three specifics: kidney dialysis is covered but limited to six sessions a year; illnesses associated with HIV/AIDS are covered, while HIV drugs come through NACA; and only NHIA-accredited facilities are covered.
What was excluded
The 2005 guidelines listed these full exclusions. Some may have changed in later revisions, which is exactly why you should ask for your own list.
| Area | Excluded in the 2005 guidelines |
|---|---|
| Injuries | Occupational injuries covered by workmen's compensation; injuries from natural disasters, conflict or extreme sports |
| Investigations | High-technology tests such as CT and MRI, except in life-threatening emergencies |
| Serious and chronic illness | Terminal illnesses including cancers; chronic renal failure; tuberculosis; stroke care beyond initial treatment |
| Surgery | Transplants, cosmetic surgery, high-cost surgery such as open-heart and neurosurgery, major congenital repairs |
| Devices | Spectacles, contact lenses, hearing aids |
| Dental | Dentures, crowns, bridges, implants, scaling and polishing, root canal treatment |
| Other | Epidemics; family planning commodities; drug abuse; infertility management; home visits; routine check-ups not linked to illness |
Partial cover
The same guidelines set partial cover for some items: the HMO paid 20% of costs for high-technology investigation in life-saving emergencies, and 20% for screening tests such as PSA, Pap smears and mammograms. Today's plans may set different shares.
Conditions you already have
Many plans treat existing conditions differently from new ones. EDOHIC, for example, covers pre-existing conditions only after six months. If you manage a long-term condition such as hypertension or diabetes, ask whether your medicines are on the plan's drug list and whether a waiting period applies before you rely on the cover for them.
Co-payments
The 2005 guidelines required formal-sector enrollees to pay 10% of the cost of each prescription at the pharmacy. State schemes set their own: Edo State's EDOHIC, for example, lists a 10% co-pay on drugs and laboratory tests and 50% on selected services.
Worked example (illustrative): a prescription costing ₦8,000 under a 10% co-pay means you pay ₦800 at the pharmacy and the HMO pays the provider ₦7,200. A ₦40,000 service under a 50% co-pay costs you ₦20,000.
Referrals and emergencies
Most plans work through a primary provider: the clinic or hospital you chose at enrolment. Specialist care is reached by referral, and the HMO usually has to approve it before the hospital will treat you on the plan. If you walk into a specialist hospital without a referral, expect to pay yourself.
Emergencies are handled differently. Edo State's scheme, for example, says emergencies can be treated at the nearest accredited facility and the scheme must be notified within 24 hours. Other schemes and HMOs set their own notice rules, so learn yours before an emergency, and save the HMO's 24-hour line in your phone.
- Before a planned procedure: ask the hospital to request the authorisation code and confirm it is issued before you are admitted.
- During a long stay: ask how many covered days remain if your plan caps them.
- After discharge: keep the bill, even if you paid nothing; it helps if a dispute arises later.
What to check first
- Ask your HMO or state scheme for the benefit schedule and exclusions list for your exact plan, in writing.
- Ask which services need an authorisation code before treatment, and how to get one at night or at weekends.
- Ask the co-payment for drugs and tests, and whether any service carries a higher share.
- Ask the annual limits, such as days in hospital or dialysis sessions.
- Ask what happens in an emergency at a non-accredited hospital.
If something covered is refused, see complaining to NHIA. To move to an HMO with better access, see choosing or changing an HMO.
Where Pryme fits
Exclusions mean most families still pay for some care. Keeping a separate naira buffer in a Flexible Savings Box helps; see Savings Boxes. For local costs of care outside cover, read healthcare costs in Lagos.
Questions people ask
Does NHIA cover surgery?
Routine and some referred surgery is usually included, but the 2005 guidelines excluded high-cost surgery such as open-heart surgery, neurosurgery and transplants. Check your plan's schedule.
Does NHIA cover cancer treatment?
The 2005 guidelines excluded terminal illnesses including cancers. Ask your HMO whether your current plan covers any cancer care.
Does NHIA pay for dialysis?
NHIA's FAQ says dialysis is covered but limited to six sessions a year.
Do I pay anything for drugs under NHIA?
Usually a co-payment. The 2005 guidelines set 10% of each prescription; EDOHIC lists 10% for drugs and laboratory tests.
Sources
- NHIS Operational Guidelines (October 2005), via Nigeria Health Watch · accessed Oct 2026
- NHIA: Frequently asked questions · accessed Oct 2026
- KPMG Nigeria: Commentaries on the National Health Insurance Authority Act (June 2022) · accessed Oct 2026
- Edo State Health Insurance Commission: Insurance policy · accessed Oct 2026
This article is general information, not financial, legal or tax advice. Products described are provided under the terms on this site and are subject to regulation and eligibility.