Majority of Kenyans cannot access quality health care services due to financial instability. The National Hospital Insurance Fund(NHIF) is the body governed by providing health insurance in Kenya. Also, it has a directive to enable all Kenyans to access quality and affordable health care services. Therefore, NHIF came up with NHIF Cover limits to ensure that every Kenyan was covered.

What are the NHIF Cover Limits?

The Kenya Essential Package for Health(KEPH) is modeled alongside NHIF to ensure there are different packages for everyone. There are different types of NHIF Cover limits that are available. For instance,

  • Inpatient cover
  • Outpatient cover
  • Maternity cover and reproductive health
  • Ex-Gratia Payments
  • Last expense cover
  • Group Life cover

Inpatient Cover

This cover under the NHIF Cover limit includes all medical treatment and services provided by or on the order of a clinician to the member. Also, this happens when the member is admitted to NHIF accredited hospitals. The package covers the following:

  • Hospital bed charges
  • Nursing care
  • Diagnostic
  • Laboratory
  • Operating theatre charges
  • Specialist’s consultation
  • All drugs and medications
  • Dressing charges

Outpatient cover

Out-patient service was launched under the National Scheme in July 2015. The NHIF cover limit is eligible to all NHIF members and their declared dependents at NHIF accredited hospitals. So, the essentials of the cover include:

  • Consultation
  • Laboratory
  • Drug administration
  • Radiology
  • Nursing services
  • Dental health services
  • Optical care
  • Physiotherapy services
  • Occupational therapy services
  • Minor surgery services
  • Referrals

Maternity and Reproductive Health Cover

Firstly, the maternity cover is fondly known as the “Linda Mama” Cover. The health scheme certainly, ensures pregnant women and infants have access to quality and affordable health services. Moreover, the overall aim of the Linda Mama Initiative by the Kenyan government is, “Achieve Universal cases to maternal and child health services and contribute toward’s the country’s progress towards UHC(Universal Health Care). Similarly, the cover is accepted in NHIF accredited hospitals. Further, the NHIF cover limit offers the following:

  • All Ante Natal Services – Some of the services covered are, for example, antenatal profile where tests are done and the preventive services.
  • All Post Natal Services

Reproductive health cover on the other hand includes family planning services, excluding fertility treatments.

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.

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

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.

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.

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.

By moseax

18 thoughts on “What Services do NHIF Cover Fund?”
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