We look at what NHIF covers (What does NHIF cover) in this article..
The government has been pushing Kenyans to take up NHIF hailing it as the best medical insurance in Kenya. But exactly what does NHIF cover?
Read on if you are not sure about what NHIF card covers
What does NHIF cover?
Well, it depends on your cover and the category of the hospital/medical facility you have been treated at.
But generally, NHIF is comprehensive and cover both curative and preventative medical services including the cost of a nearly all outpatient and inpatient medical care.
Specifically, the enhanced NHIF cover funds the following services:
- Consultation with a clinical officer, doctor, or nurse.
- Drugs administration / dispensing
- Laboratory investigations
- Radiological examinations
- Dental healthcare services
- Nursing and midwifery services
- Surgical services
- Physiotherapy services
In fact, some NHIF covers provide funding for specialist care services in certain hospitals including several NHIF Supa cover hospitals and referral hospitals.
This means you may not need to go back to your pocket to pay medical bills involving specialized surgery and ICU services (for chronic diseases) in selected NHIF accredited hospitals.
Like I mentioned, actual coverage varies according to your cover type and the hospital you’ve been treated in…
So, are there limits because that’s where most Kenyans get lost?
The answer is yes..
Here are the complete details….
What does NHIF cover?
NHIF has 2 contract plans for the healthcare providers in Kenya –non-comprehensive and comprehensive- and hospitals choose one.
Who’s under the comprehensive NHIF contract?
- All public medical facilities(all government/public facilities fall under NHIF contract A)
- A fair share of mission and faith-based medical hospitals(Theirs is called NHIF contract B)
And who’s under the non-comprehensive NHIF contract (group C)?
- All high-end private hospitals
So, how much does NHIF pay under each plan/contract?
For Group C institutions, NHIF usually pays your hospital a daily fixed amount and it’s for the bed only(Kshs.4,000-at the time of writing this).
And that means you have to foot whatever difference there’s between your hospital bill and this amount..
Example: If the hospital charges Kshs.12000 per night, then it means you’ll have to top up Kshs.8000…
Multiply that with the number of days you’re admitted and you’ll see how much you have to pay from your pocket(or from your other insurance provider, if you have one) ..
Also remember that you’ll have to add the cost of any other extra procedures/services that you have gone through or given during your treatment
What about for mission/faith-based hospitals?
First note that mission and faith-based healthcare can choose to be under comprehensive contract B plan or non-comprehensive contract B plan.
Then, here is what you need to know:
Not only will NHIF pay for the bed, it also usually pays for all other services/tests/procedures.
In addition, NHIF usually covers selected major surgical cases- so you pay for certain surgical operations yourself or with the help of your second medical insurance cover.
What about for government hospitals?
This is where NHIF covers everything..
Yeah, that’s true- if you are treated at any hospital (public/government)that’s under contract A, you won’t pay a penny ordinarily!
I say ordinarily because sometimes you are forced to buy medicine from a private chemist or undergo X-ray or another procedure outside the hospital at an extra fee now that many public medical centers are not very well equipped.
That said, NHIF requires the hospital to get authorization from NHIF In case there’s an additional charge- that is so because NHIF may cover that CT scan(or MRI) or other service even at a private hospital in some situations
So, why won’t NHIF cover everything in private hospitals and some church-run hospitals?
because those hospitals deliberately choose the non-comprehensive plan.
Reason? Profits! Period.
Yeah, these institutions need to make a profit (it’s a business, like any other) and they feel that the comprehensive NHIF packages won’t do that for them.
Does NHIF cover cancer treatment? And how much does NHIF cover for cancer patients?
When it comes to Oncology (cancer treatment), NHIF pays for radiotherapy- normally for 20 sessions at Kenyatta Hospital and a few other group A institutions.
It also pays for two(2) brachytherapy cycles (sometimes up to 3 cycles under NHIF enhanced scheme).
But you must get authorization in advance from NHIF before your hospital starts to treat you.
That involves a specialist filling out a certain form indicating the therapy planned to be administered, the total sessions scheduled, and the medicines you’ll be given.
Problem is sometimes the pre-authorisation can take long to be approved if your hospital does not fast track it which means you may end up paying for part of the treatment yourself at a private cancer center(your condition could be getting worse as you wait).
Does NHIF cover chemotherapy?
In 2021, NHIF introduced a few enhanced benefits that see cancer patients (and even those with other chronic diseases) get their chemotherapy and radiotherapy sessions paid for.
Again you need to get pre-authorization and you must be treated at a Contract A facility.
However, NHIF does not always pay for post-treatment services(e.g. medicine you use at home).
Does NHIF cover cancer screening?
Not always….for the most part you have to foot the screening bill yourself under the current arrangement.
Below now is a detailed analysis of coverage for each NHIF products..
What does NHIF cover : SUPA Cover…
NHIF’s SUPA Cover is arguably Kenya’s most popular medical insurance cover, thanks to its affordability.
Indeed, you and your whole family enjoy unparalleled benefits at just a measly Kes. 500 per month for self-employed Kenyans (the rates are higher for civil servants).
Its coverage is as follows:
- Outpatient services such as consultation, lab tests, daycare procedures, health education, drugs and dispensation, wellness and counseling, vaccines/immunization, and physiotherapy services.
- Inpatient services including maternal care (both Antenatal and Prenatal) and deliveries (Normal and C-section)
- Family planning services
- Renal dialysis for kidney patients
- Overseas treatment where the required specialized surgery is not available locally
- Rehabilitation for drugs/substance abuse
- All surgical processes including transplants
- Emergency ambulance services
- Radiology imaging services such as X-rays, CT Scans, & MRI
- Cancer treatment
The amount might be capped in some cases. Some of the NHIF cover limits are as follows…
- Inpatient services: Sh1,200 per night in most lowest-level government hospitals while this can go up to shs.4000 per night in level 5 Government hospitals.
- Maternity (normal delivery): About Shs.10,000.00
- Maternity (Caesarean Section): Up to Shs.30,000.00
- Minor Surgical Procedures: From shs. 10,000.00 up to shs. 30,000.00
- Intermediate Surgical Procedures: From shs. 40,000.00 up to shs. 80,000.00
- Major Surgical Procedures: Up to shs. 130,000.00
- Specialized Surgical Procedures: Up to shs. 500,000.00
And what does NHIF cover under the cancer cover?
Well, at the moment, NHIF covers a maximum of 20 radiotherapy sessions (at Sh3, 600 each) or up to Sh18,000 per week in public hospitals such as Kenyatta and Moi Teaching & Referral Hospital.
Yet, some cancer patients have to undergo up to 36 sessions forcing their handlers to cover the extra radiotherapy sessions from other sources or sadly, postpone treatment.
Fortunately, the insurer has heard the cry of Kenyans and is currently reorganizing its cancer insurance cover to cater for the entire prescription.
This means that NHIF will soon be paying for all your chemotherapy and radiotherapy sessions as recommended by your oncologist.
That being said, it’s not yet clear what will happen to NHIF cancer cover at private hospitals which is currently capped variously.
For example, to undergo a PET (Piston Emission Tomography) diagnostic scan at Aga Khan Hospital, NHIF will only pay up to Sh.69,500.
At the same time, NHIF has capped the cost of first line chemotherapy at some of these hospitals at Sh.25,000 per session.
This is inadequate in most cases considering that the bill can rise up to Sh.150, 000 per session for severe cancer cases.
Lastly, NHIF pays between shs. 25,000.00 to shs.150,000 per cycle (for 24 sessions annually) for oncology clinics.
What about other chronic diseases?
Under the present NHIF benefits scheme, ailments such as diabetes, kidney failure, and hypertension are catered for.
Unfortunately, as in the case of cancer, NHIF has fixed upper limits as follows.
- Radiology: Up to Sh.18,000.00
- CT scan: Up to Sh.8,000.00
- MRI scans: Up to Sh.15,000
- Monthly clinic check-up: Maximum of Sh.5,000.00
- Kidney transplant: Up to Shs.500, 000. 00
- Kidney dialysis : The cover is worth Sh.10,000. 00
What does NHIF cover under the civil servants scheme
The civil servants NHIF scheme is also enhanced and you will benefit severally.
Notably, the exact list of benefits available to you will be dependent on the agreement between the state and NHIF and typically differ across the various job groups.
Furthermore, the hospital you nominated may influence how much the cover will pay.
As a matter of fact, in some hospitals, the cover stands for bed charges only and you’ll have to turn to an independent cover or alternative means of funding to settle other costs.
And so it’s important that you research a hospital’s NHIF classification before nominating it.
But overall, majority of the highest contributors access full coverage in some hospitals.
The other limits are as I explained above though there may be a few variations from hospital to hospital.
What does NHIF cover under the Student NHIF cover?
NHIF launched the Edu Afya cover targeting all secondary school students in public schools in 2018.
To qualify, a student must have his/her details in the NEMIS (National Education Management Information System) system and be registered with NHIF (This can be facilitated by the school).
In terms of coverage, the student scheme is comprehensive and pays for outpatient consultations, diagnostic laboratory tests, and radiology services.
Besides, the cover also caters for all prescribed drugs and/or dressings, chronic illnesses, pre-existing conditions, and even day-care specialized surgery procedures.
The list is long and also includes..
- Inpatient services: Pre-hospitalization diagnostic services, hospital accommodation charges, rehabilitative services, doctor’s fees, accompanying medication, internal surgical appliances, operating theatre services, and radiological diagnostics.
- Dental problems.
- All optical ailments (rendered by one of the NHIF optical hospitals).
- Emergency services including evacuation.
- Overseas treatment if the required medical services cannot be done in Kenya.
The government pays a shs.1350 premium annually per student under the student cover.
I bet you had come here looking for answers to the question What does NHIF cover ….
And I hope I have fully answered you..
To recap, we have seen that NHIF covers nearly everything – inpatient and outpatient- but the specific amounts (where full coverage is not available) is dependent on your cover type and attended hospital.
Remember that you need to pay a shs.500 monthly premium to NHIF to benefit under the SUPA cover if you’re self-employed.
Civil servants and executives (under NHIF platinum cover) pay more according to the job group but also enjoy extensive coverage.
You can contact NHIF on (020) 2723246 for further clarification.