Here is a breakdown of the various NHIF cover limits for both inpatient and outpatient medical services.
NHIF cover limits: Outpatient services
NHIF covers outpatient services including consultation fees, physiotherapy services, drugs dispensation, laboratory examinations, wellness and counseling, health education, and immunization.
In most cases, there are no NHIF Supa cover limits for outpatient services as long as you are attending a registered hospital.
Indeed, the enhanced NHIF cover the full cost for outpatient services but for a few exceptions.
NHIF cover limits: Inpatient Services
The insurer also covers bed charges, consultation, nursing care, medication, surgery, physiotherapy, laboratory services, specialist consultation, and accompanying treatment.
Others include accident fractures and blood transfusion procedures.
The applicable limits (bed charges) as follows:
- Low-cost government hospitals: From shs.1200.00 daily.
- High-cost private hospitals: The maximum coverage is Sh.4, 000 per day.
Limits for the other services depend on the hospital category.
Civil servants cover limits: Inpatient and Outpatient Services
For public servants, the cover is limited for both inpatient and outpatient services in some job groups.
Take a look.
|Job group||Outpatient (shs)||Inpatient (shs)|
NHIF cover limits: Maternity Services
NHIF pays for both normal delivery and C-section in public hospitals as well as the majority of private hospitals.
The cover also caters for prenatal care services and has these limits:
- Normal child delivery: Up to shs.10,000.00
- Caesarean section: Up to Sh30,000.00
A huge amount of NHIF maternal healthcare cover goes to Linda Mama where NHIF pays everything.
NHIF cover limits: NHIF cancer cover (Oncology package)
Unlike in the past, NHIF caters for different types of cancer treatments and has been aiding Kenyans from all walks of life access critical care.
In fact, NHIF is currently reviewing its cancer care plan and is hoping to be able to settle the whole chemotherapy and radiotherapy cost in the near future.
That being said, the amount payable is at the moment limited as follows:
Under Supa Cover, NHIF pays for 20 radiotherapy sessions (maximum) at KSh3,600.00 each or a maximum of KSh18,000.00 per week in government-owned hospitals such as MTRH (Moi Teaching & Referral Hospital) and KNH (Kenyatta National Hospital).
The limits are a bit higher at some top-notch private hospitals. For instance, the limit for first-line chemotherapy at this category of hospitals is capped at Ksh.25,000.00 per session (maximum is 6 chemo sessions).
For severe cases, the cap is KSh.150, 000 per session (4 sessions maximum).
Lastly, the cover pays 2 sessions for Brachy-therapy at Kshs.40000.00 each.
2. Diagnostic tests
Advanced tests are covered too but have various limitations especially in high-cost hospitals.
For example, the scheme pays a maximum of KSh.69,500.00 for Piston Emission Tomography scan at the Aga Khan Hospital.
3. Oncology clinics
For NHIF member attending oncology clinics, the benefits are between Kshs.25,000.00 – Kshs.150,000 per cycle (But not beyond 24 sessions annually).
NHIF cover limits: Chronic diseases including Kidney Treatment
Besides cancer, the current NHIF scheme also caters for diseases such as diabetes, hypertension, and kidney failure.
The cover has the following upper limits.
- Radiology services: Maximum coverage is Sh.18,000.00
- Monthly clinic check-up: Maximum of Sh.5,000.00
- Kidney transplants: Maximum is Shs.500,000.00
- Kidney/renal dialysis: The cover pays up to Sh.9500.00 for each session (2 times per week)
NHIF cover limits: Imaging Services (Radiology package)
Basic ultrasound and X-rays are catered for under the outpatient and inpatient medical care in most hospitals while CT scans and MRI are available in several contracted facilities.
The scans are also paid under inter-hospital referral system though you may need a preauthorization from NHIF to qualify.
Take a look at the limits..
- CT scans: Up to KSh.8,000.00
- MRI scan: Up to KSh.15,000
- Ultra sound: Up to Kshs.3,000
NHIF cover limits: Surgeries
Major, minor, and specialized surgeries package are capped at an average of Ksh500,000.00 per person depending on the hospital level and the procedure you’re undergoing.
Overall, the cover is as follows…
- Minor Surgical Procedures: Cover starts at Kshs. 10,000.00 – Kshs. 30,000.00
- Intermediate Surgical Procedures: The scheme covers Kshs. 40,000.00 – Kshs. 80,000.00
- Major Surgical Procedures: Benefits are capped at shs. 130,000.00
- Specialized Surgical Procedures: NHIF pays up to Kshs.500,000.00 for registered NHIF beneficiaries
NHIF cover limits : Dental Care
The Dental Cover from NHIF covers dental consultation, root canal, dental X-rays, dentures, orthodontics, cost of filling, and extractions -including surgical extractions.
Dental anaesthetics fees and operating theatre cost are also covered.
The provided limits are per service basis but won’t exceed shs.50,000.00 annually, per family.
NHIF cover limits : Optical services
For all Job Groups, the limit is shs. 40,000 annually, per family for optical care services obtained from accredited hospitals.
Services not covered by the NHIF
The benefit package has several exclusions meaning you can’t claim payment for them. These include but are not limited to:
- Cosmetic or beauty treatments and/or cosmetic surgery.
- Massage (except where medically certified in the course of physiotherapy because of an accident or related illnesses).
- Any treatments obtained from non-accredited hospitals and/or un-authorized referrals.
- Expenses recoverable from other insurance schemes.
- Treatment delivered by acupuncturists, chiropractors, and herbalists or costs resulting from treatments received from nature cure clinics and related establishments.
- Vaccines but KEPI vaccines, Anti – rabies, Rota virus vaccine, Anti –Snake venom, and Yellow Fever (NHIF liaises with the health ministry and county governments in providing these Vaccines).
- Obesity-related treatments.
- Charges recoverable under WIBA (Work Injury Benefits Act) or such medical plans.
- Any other treatments/care restricted in the NHIF contracts negotiated with employers.
What to know about the various NHIF scheme
- You can easily update your dependents details by visiting any NHIF office in addition to Huduma centres.
- You should seek NHIF pre-authorization if you are scheduled to undergo more than two radiology sessions weekly for the cover to pay for the extra cost.
- For extremely special cases, the facility may request you to obtain NHIF pre-authorization from the insurer prior to clearance. In such a case, you will be asked for a comprehensive medical report, completed NHIF Pre-authorization form, Pro-forma invoice, National ID card, and a scanned copy of your NHIF card.
The thing is the NHIF cover limits vary from hospital to hospital and jobs groups (for civil servants) so you should look at the above analysis as a guide.
The best way to know exactly how much the insurer will pay for you is to enquire from the medical facility or contacting NHIF directly on (020) 2723246.
All in all, you have a starting point.