TSC medical scheme- Educationnewshub
TSC medical scheme- Educationnewshub

The Teachers Service Commission, TSC, has finally released guidelines on the Teachers’ 2019-2022 medical scheme by Minet. The Contract, between TSC and Minet, to offer medical insurance to teachers and their dependents was renewed in November, 2019.

“The Teachers Service Commission procured and awarded Minet Kenya Insurance Brokers the contract for provision of Medical cover for all teachers and their dependants with effect from November 1, 2019,” says the TSC Boss Dr. Nancy Macharia via a circular dated March 12, 2020.

The latest guidelines detail the medical scheme benefits for members pegged on their respective job groups (See featured photograph for benefits per job group).

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MEMBERSHIP ELIGIBILITY

According to TSC, the following are eligible to benefit from the medical scheme:

  1. All teachers in active service aged 18 years up to 65 years.
  2. One (1) legal spouse of the teacher
  3.  Four (4) dependent children (biological/legally adopted) are eligible for cover from birth until the age of eighteen (18) years or to the age of twenty (25) years if residing with their parents and enrolled in a recognized post- secondary institution.
  4. No maximum age limit shall apply to child dependants with disability.

The maximum family size is Six (6), comprising of principal member plus five dependents.

CO-PAY

teachers visiting accredited facilities will have to part with a consultation (Co-pay) fee of Kenya shillings Fifty (Ksh.50) per visit per individual for Outpatient, Dental and Optical doctor consultation services.

The Co-pay shall not, though, be charged for Maternity and related conditions, in repeat visits for these services within seven (7) days from the date of previous visit and when picking medication for chronic conditions that may not require consultation with a doctor.

SCOPE OF COVER

The newly signed medical cover includes inpatient, outpatient, dental Optical, Maternity, Local and International Medical Emergency evacuation.

INPATIENT BENEFITS

This is a treatment which requires admission in and stay in a hospital or day care surgery/ procedure. The benefits (paid after subtracting NHIF rebates) under this cover include but not limited to:

  • Bed entitlement: Job Group B5 to D2 (Standard ward bed) and Job group D3 to D5 (Standard Private Wing),
  • Doctor’s (Physician, Surgeon & Anesthetists) Fee.
  • ICU/HDU/Critical care and theatre Charges
  • Drugs/Medicines, dressings and internal surgical appliance
  • Pathology/Laboratory
  • X-ray, Ultrasound, ECG and Computerized Tomography, MRI Scans
  • Radiotherapy and Chemotherapy
  • In-Patient Physiotherapy, Hydrotherapy
  • Occupational therapy
  • Hospital accommodation for accompanying parent and /or guardian for hospitalized children below seven (7) years
  • Medical education and wellness program for members with pre-existing and chronic conditions
  • Medical Emergency Road evacuation services leading to admission
  • Congenital defects/genetic disorders
  • Post- Hospitalization benefit of up to two (2) weeks for other sicknesses and six (6) weeks for accident cases after discharge.
  • Day care Surgery for minor surgical treatment that may not require admission
  • In-vitro Fertilization (IVF)
  • Renal dialysis
  • Cancer Treatment and related procedures and tests
Outpatient Benefits

This is treatment that does not require admission or stay in a hospital or day care. The outpatient benefits include but not limited to: –

  • Routine outpatient consultations.
  •  Prescribed Diagnostic Laboratory and Radiology services (X- ray, ultrasound, MRI and CT Scans).
  • Prescribed physiotherapy
  • Prescribed drugs and dressing.
  • Referral Outpatient to specialists.
  •  HIV/AIDS related conditions and prescribed ARV’s to the full cover limit per family per annum.
  • Newly diagnosed chronic conditions
  •  Pre-existing chronic conditions (including cancer)
  • Pap smear for ladies and PSA for men- (for principal members only)
  • Medical Emergency Road ambulance evacuation services.
  • Rehabilitation service as per limits
  •  Preventive care: to include free Medical camps, Mobile Clinics for events, counselling on
    lifestyle and wellness
  •  Prescribed preventive and curative drugs/care (Including pressure stockings and clinical
    corset belt)
  • There shall be portability with no restrictions to panel of medical providers. Teachers are free to visit any medical service provider within the Country; within list of selected hospitals.
Maternity Benefits

Benefits under this cover include but not limited to; –

  • Delivery/ Doctors Fees
  • Routine Antenatal check-up
  • Postnatal care up to six (6) weeks post-delivery
  • Routine Immunizations (KEPI) and Baby Friendly Vaccines
  • 1st emergency caesarean section, subsequent elective CS and normal delivery
  • Pre-maturity/Pre-term
  • Congenital conditions

NB. The maternity benefit is available to principal members and/or their spouse only.

FOR A COMPLETE GUIDE TO ALL SCHOOLS IN KENYA CLICK ON THE LINK BELOW;

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 Dental Benefits

Benefits under this cover include but not limited to; –

  • Dental Consultation and Anesthetist’s fees
  • Dental X-rays and Root canal treatment.
  • Tooth Extraction
  • Saling necessitated by a prevailing medical conditions and prescribed by a dentist
  • Dentures necessitated by an accident/ injury
  •  Deformation surgery
 Optical Benefits

Benefits under this cover include but not limited to;

  • Cost of lenses and frames- members who have obtained frames will not be entitled to a replacement within one year unless necessitated by a medical condition and prescribed by an ophthalmologist.
  • Prescription for ophthalmic treatment and eye lenses
  •  Ophthalmic ultrasound if prescribed by the Ophthalmologist
Medical Emergency Road and Air Evacuation Benefits

This benefit allows for emergency transportation and transfer of sick or injured members or dependents from a place of incident or facility with inadequate care to the appropriate facility using road ambulance, fix-wing and helicopter services within East Africa (Kenya, Uganda, Rwanda and Tanzania). Air evacuation will be limited to two (2) per family per annum within the policy period.

 International Travel and Referral Allocations

This will be paid out where authorization has been granted for the member to travel to another country for specialized treatment which is either not available locally or is reasonably cheaper and better quality than is locally, air ticket for patient and aide and their accommodation. A medical referral report shall be required to facilitate overseas treatment.

All requests for specialized treatments outside Kenya shall be approved by the Director, Medical Services in the Ministry of Health.

 Psychiatric and Counselling Services

Provision of Psycho-social support programs for employees for conditions such as chemical dependency, stress, post-traumatic counselling, relationship difficulties, anxiety and depression, parenting, legal or financial distress etc. services will include but not limited to:

  • Psycho-Social tele-counselling services through Minet Tele-counselling center.
  • On site counselling services in some special instances
  • Referral for face to face counselling by specialist.

MEDICAL SCHEME EXCLUSIONS

The medical scheme will not cover the following:

  • Active participation in war, invasion, riots or terrorism
  • Cosmetic treatment unless relating to an accident
  • Massage (except where certified as medically necessary)
  • Nutritional supplements unless prescribed by a doctor as part of treatment of a deficiency
  • Maternity cover for dependent children
  • Self-prescribed drugs
  • Treatment other than by a registered medical practitioner
  • Outpatlent, dental and optical co-pay of fifty shillings on each visit
  • Reimbursement of costs incurred outside the appointed panel of providers unless for emergency cases, accident cases and on pre authorization
  • Private vaccines and travel vaccines
  • Alcohol related rehabilitation
  • Maternity for child dependants
  • Cost of lenses and frames not prescribed by an Ophthalmologist
  •  Replacement of spectacle frames within the same year of cover.
  •  Photo chromatic and/or antiglare lenses unless prescribed by a doctor
  • Cosmetic dental care Cosmetic Crowns, Caps, Bridges, Orthodontics & Dentures, self-prescribed teeth cleaning and whitening, unless necessitated by
  • Infertility investigation and family planning procedure expenses
  • Replacement or repair of old dentures bridges and plates unless damage to dentures, bridges and plates becomes necessary as a result of accident
  • Treatment otherwise covered by NHIF
GROUP LIFE AND LAST EXPENSE (FUNERAL) COVER
a) Last Expense Benefits

The Last Expense (Funeral) cover provides a fixed amount graduated per grade and payable only in the event of death of the principal member to defray funeral expenses.

b) Group Life Benefit

A fixed amount to be paid graduated according to grade as per the table of benefits above. This will be a benefit rider under the Health Care Medical Scheme.

SERVICE PROVIDERS

Members may view a full list of medical service providers through: –

  •  TSC and MINET Kenya websites
  •  Use of Mobile phone USSD code – dial *340#

Teachers and their dependants are required to access medical care services only from the approved panel of service providers. The Administrator shall not reimburse costs incurred outside the appointed panel of providers except for emergency cases.

CONTACTS FOR ENQUIRIES

Members may direct their enquiries to Minet Kenya through:

NB: Fraud and Malpractices:Teachers are strongly advised not to engage in fraudulent activities.

BEST LINKS TO TSC SERVICES & DOCUMENTS; ONLINE

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