NHIF Comprehensive Medical Insurance Scheme – Full details

On 1st of January, 2012, the Government introduced a Comprehensive Medical Insurance Scheme for Civil Servants and Disciplined Services together with their eligible dependants. The scheme has continued to improve and the provisions of the scheme are as follows:

  1. The medical cover caters for the principal member, spouse and five declared children of up to 21 years of age and/or a maximum of twenty five (25) years of age if still in full time formal education (M+6);
  1. Members and their eligible dependants access outpatient, inpatient and specialized medical services in NHIF accredited Government, Mission and Private Health Facilities across the Country;
  • Members are expected to choose their preferred Health Care Facilities as per the list of hospitals provided by NHIF;
  1. Inpatient treatment is without limits/ceilings in Amenity wards in Government, Mission and some private hospitals for officers in Job Groups A-K while it has specialized limits/ceilings in high cost private hospitals for officers in Job Groups L-T and their eligible dependants;
  2. The scheme caters for treatment outside the country for medical conditions whose treatment is not available in All costs in terms of Medical expenses, travel costs and stay outside the hospital for the patient (member or dependant) and the person accompanying the patient is covered subject to preauthorization by NHIF;
  3. NHIF shall meet foreign travel and accommodation costs for the

patient’s organ donor subject to preauthorization;

  • NHIF will reimburse expenses arising while a member is temporarily abroad on official duty and requires emergency treatment for an illness or injury that occurs during the period of travel, provided that such period does not exceed six weeks (6) in any visit;
  • The scheme provides for local road ambulance services for transportation and transfer of a sick member or dependants for treatment to the nearest Health Care Facility (emergency only) or an NHIF accredited hospital;
  1. Emergency Air Rescue Services for transportation and transfer of an injured member of the Scheme to an NHIF accredited facility; and
  2. The cover also provides for Group Life and Last Expense for the principal members at graduated rates based on individual officer’s Job Group.

 

 

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              MEMBERSHIP

  • Eligibility

The following are eligible for the cover:

  1. Civil Servants at the National Government, Staff performing functions

devolved to the Counties.

  1. Declared spouse by the principal member;
  • Five declared children upto 21 years of age or 25 years for a child enrolled in a full time formal education;
  1. There is no age limit for dependants with Disability (proof of registration with the National Council for Persons with Disability will be required);
  2. More dependants can be covered on payment of an additional premium as provided in Table A; and
  3. Principal Members must register with

 

  • Table A- Additional Dependant(s) Premiums(Per Year)
 

Job Group

Premium for Each Addi- tional Dependant(s) (KSH) Premium for Unlimited Dependant(s) (KSH)
Option 1 Option 2
A-G 3,500 6,000
H 3,500 6,000
J 3,500 6,000
K 3,500 6,000
L 3,500 6,000
M 3,500 6,000
N 6,000 12,000
P 6,000 12,000
Q 6,000 12,000
R,S,T 9,000 20,000

 

  • Registration Requirements

The Members that have never registered with NHIF before or declared their dependants are required to fill a Registration form (NHIF 2) available at any NHIF office, Huduma Centres or NHIF website (www.nhif.or.ke). The applicant must attach:

  1. Coloured passport size photos of contributor and all declared

dependant(s);

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  1. Photocopies of identification cards for contributor and spouse (where

applicable); and

  • Copies of birth certificates for all children or birth notification for child(ren) below six (6) months and adoption certificate and disability identification, where

 

  • Registration Updates

If an employee is already a registered member of NHIF, they should ensure the details of their dependants are accurately reflected in the NHIF records by confirming at the nearest NHIF office or Huduma Centre or calling the toll free line 0800 720 601. A member may wish to add or amend his or her details or those of the dependants as follows:-

 

  • Declaration of Spouse

Fill NHIF 26 form (see Appendix II) and attach copies of I.D for Member and the Spouse together with coloured passport size photograph of the spouse.

 

  • Declaration of Child

Fill NHIF 26 form and attach a copy of the birth certificate or birth notification for a child below six (6) months, adoption certificate or disability identification, where applicable.

 

2.3.3.Change of Spouse

Fill in NHIF 26 form and attach the following documents:

  1. Copies of D for member and spouse
  2. Coloured passport size photo of spouse
  • Marriage certificate/Affidavit from a Commissioner of Oath; and
  1. Death Certificate/Divorce

 

2.3.4 Amendment of Member Details

Fill NHIF 26 form and attach copies of I.D and state on the form the required amendments or change requested.

 

 

 

 

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              CHOICE AND CHANGE OF FACILITY

Choice or selection of preferred outpatient facilities is done every June and December of the contract year. NHIF will inform the members when the period is due for submission of the form for change of facility. The following guidelines shall be applicable:

  1. To choose a preferred outpatient facility one MUST be duly registered and their dependants
  2. A principal member can choose a different facility for each beneficiary where necessary (ONLY ONE facility is allowed per beneficiary).
  • To select a medical facility, the Principal member should refer to the list of NHIF accredited health facilities available in the NHIF Website (www.nhif.or.ke), NHIF offices and Huduma Centres Country
  1. Members who are comfortable with their current facilities need not
  2. Members on transfer during the capitated period can change to another facility by providing a copy of transfer
  3. Members can still submit their forms after the deadline but the change shall ONLY take effect from the next stipulated

 

  • Requirements for Choice and Change of Facility
  1. The Principal member completes Change of Facility Form (NHIF 38)

(see appendix iii) and submits it to the nearest NHIF Office.

  1. A copy of the Principal Member’s National ID MUST be

 

 

 

 

 

 

 

 

 

 

 

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              BENEFITS PACKAGE

The scope of benefits includes comprehensive outpatient and inpatient medical treatment both within the country and overseas for the principal member and eligible dependants. In addition the cover provides for Group Life and Last Expense Cover for the Principal Member.

 

  • Out-patient Cover

The outpatient benefit package includes both curative & preventive services which comprise, but not limited to:

  1. Consultation
  2. Laboratory investigations
  • Drugs administration & dispensing
  1. Dental health care services
  2. Radiological examinations
  3. Nursing and midwifery services
  • Maternal Child Health/Family Planning
  • Minor surgical procedures
  1. Optical care
  2. Rehabilitation services
  3. Annual medical check-up
  • Referral for Specialized Services
  • Ambulance services
  • Day care services such as Manual Vacuum Aspiration (MVA), surgery and other medical services deemed fit by the clinician e.g. cases whereby a clinician may use the local anesthesia to numb a particular part of the body which may include minor surgery like incision, drainage and suturing of

 

  • Dental Care

The Dental Cover includes dental consultation, orthodontics, root canal, dentures, Cost of filling, X-rays and Extractions including surgical extractions together with anaesthetics fees, hospital and operating theatre cost. The Dental Cover can be accessed as per the provided limits in Table B on a Fee for Service basis.

 

  • Optical Care

A member shall benefit in the proportion of expenses on a Fee for Service

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basis as shown on table B for the cost of the eye glasses and eye testing.

 

  • Table B- Dental and Optical Limits(Per year, per family)
Job Groups Optical (KES) Dental (KES)
All Job Groups 40,000 50,000

 

NB.Provided the total cost in any one period of insurance does not exceed

the limits specified in Table B.

 

  • Tests for Organ Donor(s)

NHIF shall meet the pre-test costs for the kidney donor identification upto a maximum of two (2). The potential donors shall be a paid up registered member/be enrolled as a member of NHIF.

 

  • Annual medical Check

The principal member and spouse are eligible for annual general medical checkup at the selected healthcare facility. Medical checkup will entail examination of the following:

  1. Body mass index
  2. Full Haemogram
  • Cholesterol
  1. Blood sugar
  2. Gamma GT
  3. Urinalysis
  • PSA(Prostate Specific Antigen for Men above 40)
  • Pap smear for all women
  1. Mammogram

NB:Health Care Facilities that are unable to offer the above scope of services are advised to refer the member to other facilities (members shall not be required to pay for these services on referral)

 

  • Vaccinations

KEPI vaccines, Rota virus vaccine, Anti – rabies, Anti –Snake venom and yellow fever vaccine are catered for in the scheme. The vaccinations will be availed at the selected health care facilities.

  • How to Access Out- Patient

Members are expected to seek Out-Patient treatment in their selected

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medical facility. Members in job groups A-K will have unlimited outpatient services in their selected facilities. Members in job groups L-T will access outpatient services in their selected facilities subject to their annual limits as indicated in Table C.

The following documents are required at the point of service:

  1. A copy of NHIF card OR
  2. A copy of the National Identification card of the principal member or Staff Identification

 

  • In-patient Cover

Inpatient care may include all medical and surgical conditions which need admission and where the management will be of therapeutic value. The Inpatient cover includes the following:

  1. Hospital accommodation charges
  2. Nursing care
  • Diagnostic, laboratory or other medically necessary facilities and

services

  1. Rehabilitation services
  2. Operating theatre services
  3. Specialist consultations or visits
  • Radiology services
  • Drugs prescribed by treating clinician
  1. Pre-hospitalization procedures such as laboratory, x-ray or other

medical diagnostic procedures and tests

 

  • Maternity and Reproductive Health Cover This cover includes the following:-
  1. Consultation and treatment for both mother and child,
  2. Cost of Child birth including caesarian section deliveries
  • Family planning

 

  • How to Access In-patient Services

In-patient treatment will be on referral basis from the selected primary healthcare facility. These services will be accessed as follows:-

  1. Members in Job Group A-K will access comprehensive benefit in case they fall sick in Private wing in the two National referral hospitals (KNH and MTRH), Amenity wards in Government hospitals and Ward Beds

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in Mission and Medium Cost Private Hospitals in facilities designated to them.

  1. Members in Job Group L-T will access comprehensive benefit subject to their limits in Private wing in the two National referral hospitals (KNH and MTRH), Amenity wards in Government hospitals and ward beds in Mission and private Job Group R, S, T – can access private single rooms in the facilities designated to them.
  • Members seeking In-Patient treatment are required to provide:-
  1. A copy of NHIF card;
  2. A copy of the Principal Member’s National Identification card;
  3. A copy of the spouse’s National Identification card in case the spouse

is the patient;

  1. Copy of birth certificate or birth notification for child(ren) below six

(6) months or copy of adoption certificate where applicable in case

of child admission;

  1. A copy of proof of registration with the National Council for Persons with Disability will be required for dependants with Disability and are over 21 years;
  2. A letter of proof that the child is enrolled in a full time learning institution for children above 21 years will be

 

  • Table C: Outpatient and Inpatient Annual Limits
Job Groups In- Patient Out-Patient
A-G Unlimited Unlimited
H Unlimited Unlimited
J Unlimited Unlimited
K Unlimited Unlimited
L 1,000,000 100,000
M 1,250,000 150,000
N 1,500,000 200,000
P 1,750,000 225,000
Q 2,000,000 250,000
R,S,T 2,250,000 350,000

 

  • Emergency Treatment

Incase of a medical emergency, members and/or their declared

dependants will access services in any NHIF accredited health facility.

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The facility should communicate to the nearest NHIF office for purposes of reimbursement. Members are expected to report cases of emergency or emergency admissions to the nearest NHIF office.

Members will not be required to meet the cost of such treatment.

 

  • Referrals

The contracted Health Care Provider has a proper referral system and shall refer the beneficiaries to a lower level facility or higher level facility depending on the medical and health care services required. The types of referral may be;-

  1. Outpatient to outpatient: Referral from a lower/higher level facility
  2. Outpatient to inpatient: Referral for inpatient
  • Inpatient to inpatient: Referral from a lower/higher inpatient

 

  • Referral Protocol

A scheme member will seek treatment in their selected health facility. However, where the selected facility lacks a particular service, the facility shall refer the member to any other health provider where the service is available. Such referrals shall be paid for by the member’s selected health facility. These shall exclude dental and optical which are paid on Fee for Service basis.

 

  • Notification/Letters of Undertaking

The hospital will notify NHIF for authorization in cases of day care surgery, and when a member is away from their capitated facility. The authorization shall be issued by the Branch Manager, Deputy Branch Manager or Head of Benefits.

A Letter of Undertaking will be required for specialized cases. The member will be required to visit his outpatient facility for a referral letter before visiting the nearest NHIF Branch office to be issued with a letter of undertaking.

 

  • Overseas Treatment
  1. Treatment costs for beneficiaries arising from a condition that warrants treatment not available in Kenya will be covered subject to pre- authorization by NHIF will cater for treatment cost and cost

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of travel for Member or Dependants and travel and accommodation costs for one person accompanying the patient.

  1. Medical personnel accompanying a patient on recommendation by the referring Doctor will be paid for a return air ticket and accommodation for a period not exceeding two
  • In cases of organ transplant, NHIF will also cater for treatment and

travel cost for the organ donor.

  1. NHIF will reimburse claims related to emergency treatment incurred while the principal member is temporarily outside the country on official duty as long as the period is not exceeding six weeks at any one visit.

 

  • Requirements for Overseas Treatment

Referral letter from the facility or specialized consultant.

A letter from line ministry/department to the Director of Medical Services

supporting the referral.

Approval letter from the Director of Medical Services. Pro-forma invoice from the referred facility.

NB: An NHIF approved agent may assist members to identify appropriate facilities and make travel arrangements. For more information contact the nearest NHIF Office.

 

  • Emergency Rescue Services
    • Local Road Ambulance

Ambulance services for transportation and transfer of a sick member or dependant for treatment to the nearest NHIF Accredited Health Facility is provided as follows:

  1. Emergency road transfer services by Kenya Red Cross Society is for all Civil Servants and Disciplined Services members/dependants covered under the
  2. Members can access Kenya Red Cross Helpline 24 hours a day through

a toll free line – 1199.

 

  • How to Access

When there is need for a medically indicated transfer or during a medical emergency:

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  1. A call shall be made to any of the Emergency Medical Dispatch

numbers (0700 395395, 0738 395395) for an ambulance;

  1. A call can also be made to the Toll free line – 1199;
  • The caller should state the principal member’s full names, NHIF number, location/facility, nature of the emergency, telephone number and or where to be transferred to; and
  1. The caller shall be requested not to hang up until the dispatcher allows

him/her.

  1. The nearest available ambulance shall be dispatched to the location or site immediately after verifying membership

 

  • Emergency Air Rescue

Emergency Air Rescue is available for transportation and transfer of an injured Principal member of the Scheme to health facilities where adequate treatment is available. AMREF Flying Doctors has been contracted to provide emergency air rescue services to the Civil Servants & Disciplined Services officers spread across the country.

The cover includes:

  1. Two evacuation flights per year per member; and
  2. Two ground ambulance transfers per year within The Service Provider will facilitate a local road ambulance to transfer the patient from the airport/airstrip to the nearest N.H.I.F accredited Health Care Provider.

 

  • How to Access
  1. In case of emergency contact the emergency control centre through telephone Numbers : 0733 639088,0722 314239,020 662299,Email: [email protected]
  2. State your name, telephone contact, location/facility and nature of

emergency.

 

 

 

 

 

 

 

 

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5.0 SPECIALIZED SERVICES

NHIF shall cover a member or dependants for Dental, Optical, Pressure Stockings, Orthodontics, Root canal, Dentures, Hearing Aids, Drug and Substance Abuse Rehabilitation Services, Renal, Trauma, Diabetes, Hypertension, In Vitro Fertilization (IVF) treatment, MRI, CT- Scan, and Cancer medical care and treatment services.

The total coverage under this section in any one period of insurance shall not exceed the limits specified and the cover shall be available at NHIF accredited and contracted specialized facilities from the selected health facility.

6.0 LAST EXPENSE

NHIF shall, upon death of a principal member while this cover is in force pay to the next of kin the amount specified in the Last expense schedule below to cater for the funeral expenses. The declared next of kin will be required to complete the form and forward to the respective head of human resource management in the line Ministry /State Departments/ County the following documents:

  1. Original burial permit; and
  2. Duly completed claim

7.0 GROUP LIFE

NHIF shall pay death benefit upon the demise of a principal member only. The declared next of kin will be required to complete the form and to forward to the respective head of human resource management in the line Ministry /State Departments/County the following documents:

  1. Original burial permit;
  2. Original Surrender of D. form;
  • Original death certificate; and
  1. Duly completed claim

The Original documents will be returned to the next of kin after payment.

For last expense and group life the Line Ministry /State Departments/

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County Heads of Human Resource Management shall forward the above documents to NHIF for payments.

NHIF shall pay Permanent Total disability benefits upon the disablement of a member equivalent to Group life benefits, whilst in service within seven(7) days on receipt of full documentation.

NHIF shall pay critical illness benefits of 30% of group life benefits upon the diagnosis of a critical illness of a member, whilst in service within seven

(7) days on receipt of full documentation.

NHIF shall pay for artificial appliances such as wheel chairs (one within the contract period), crutches, prosthesis and walking frames as necessary prescribed by medical practitioner within seven (7) days on receipt of full documentation.

 

  • Procedure for accessing Last Expense and Group Life Cover
  1. All notifications of death to NHIF should be signed by the Head of Human Resource Management Unit or in their absence, the Deputy Head of HR Unit in the respective Line Ministry/State Department/ County of the deceased officer within thirty (30) days of occurrence. Any notification/claim not signed by the Head/Deputy of HRM Unit will not be
  2. The Head of Department at the County/Sub County should complete and sign Part I of the Claim Form, ensure that the beneficiary/next of kin completes Part II and forward the form to the Head of HRM Unit at the line Ministry/State
  • Department /County for onward transmission to
  1. The Head of Human Resource Management Unit must certify that the claimant is the eligible beneficiary before forwarding the claim form to NHIF and they will be held personally accountable for inaccurate
  2. The Head of Human Resource Management Unit at the line Ministry/ State Department/County are required to submit their specimen signatures and those of their Deputies for verification of the claim form

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  • Table D: Group Life and Last Expense
Job Group Group Life (Kshs) Last Expense (Kshs)
A-G 700,000 100,000
H 700,000 100,000
J 700,000 100,000
K 850,000 120,000
L 850,000 120,000
M 1,000,000 150,000
N 1,000,000 180,000
P 1,150,000 200,000
Q 1,300,000 250,000
R,S,T 1,700,000 300,000

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

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              OBLIGATIONS

The scheme has three parties the member, NHIF and the Health Care Facility, whose roles are outlined below;-

 

  • Obligations of the Member The member shall:
  1. Register with NHIF and declare all eligible dependants;
  2. Provide necessary and correct documentation & information of

themselves and dependants;

  • Update all beneficiaries in a timely manner;
  1. Not engage in fraudulent activities in order to unlawfully obtain

benefits; and

  1. Abide by the provision of the Contract on benefit package and

selection of health care providers.

  1. Where a member is not able to access services as stipulated, they are encouraged to call or visit the nearest NHIF office for further

 

  • Obligations of the Health Care Providers The health care provider shall:
  1. Render the agreed range of health services to bonafide Scheme members and their beneficiaries;
  2. Maintain high standards of quality healthcare services;
  • Not engage in any fraudulent activities in order to unlawfully obtain

payments or any other benefits.

  1. Fully abide by the provision of the contracts signed between the facility and NHIF.

 

  • Obligations of NHIF

The obligation of the Fund in relation to the Member and Health Care providers shall be as follows:

  1. Accredit and contract healthcare providers;
  2. Provide a list of accredited and contracted healthcare facilities;
  • Register and issue members with membership cards;
  1. Receive premiums;
  2. Ensure adherence to the terms of agreement by all parties;
  3. Pay the service providers in a timely manner; and
  • Sensitize all stakeholders on the

 

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9.0 EXCLUSIONS

Exclusions are those services which are not covered in the benefit package. They may include but not limited to expenses incurred by a beneficiary as a result of:

  1. Cosmetic or beauty treatment and/or surgery;
  2. Massage (except where certified as a necessary part of physiotherapy

following an accident or illness);

  • Treatments arising from non-accredited health facilities and/or un- authorized referrals;
  1. Expenses recoverable under any other insurance;
  2. Treatment by chiropractors, acupuncturists and herbalists or stays and /or maintenance or treatment received in nature cure clinics or similar establishments or private beds registered within a healthcare provider, convalescent and /or rest homes with ‘cures’ attached to such establishments;
  3. Vaccines except KEPI vaccines, Rota virus vaccine, Anti – rabies, Anti

–Snake venom, Yellow Fever (NHIF to liaise with the Ministry of Health

and County Governments in the provision of the Vaccines);

  • Investigations, treatment, surgery for obesity or its sequel, cosmetic or

beauty treatment and or surgery;

  • Claims expenses for Members who are outside the country on official

duty for a period exceeding more than six weeks at any one visit.

  1. Charges recoverable under any Work Injury Benefits Act (WIBA) or

any other medical plan; and

  1. Any other restrictions as provided for in the negotiated

 

                    FREQUENTLY ASKED QUESTIONS

Q1. What happens in case of Emergency and away from facility chosen? You will be treated in the NHIF accredited health facility nearest to you.

Q2. Are my parents covered?

  1. The cover is only for principal member, declared spouse and

dependants.

Q3. What happens to my medical limit if I don’t use it?

It lapses at the end of the financial year.

Q4. What happens once the limits are exhausted?

There are no extensions once the limit is exhausted, however the Principal Member may apply to the Principal Secretary for medical ex-gratia assistance.

Q5. Why choose a facility?

The scheme allows members to choose a healthcare facility for ease of accessing quality services.

Q6. Can I choose a different facility for each dependant?

Yes. You can choose a different facility convenient to each dependant.

Q7. Is one required to choose an inpatient facility?

  1. For inpatient one can be admitted in any health facility subject to the NHIF contract with the facility.

Q8. What happens when one is transferred?

One is allowed to change healthcare facility.

Q9. Is a member still covered once interdicted?

YES. A member remains covered.

Q10. Why limit the number of beneficiaries?

To maintain sustainability of the scheme based on government funding.

Q11. Do I have to do a medical test/examination before joining the

scheme?

  1. But under the scheme the principal member is entitled to a voluntary annual medical check-up.

Q12. Once referred who should settle the bill?

Bills will be settled by the selected healthcare facility for outpatient services and NHIF for inpatient services.

Q13. If I’m unhappy with the services, how can I be assisted?

You can raise it as a complaint through the existing channels.

Q14. What of disabled dependants who are over 25 years of age?

They remain beneficiaries under the scheme.

Posted in Health and Lifestyle.

Media Team @Educationnewshub.co.ke

View posts by Media Team @Educationnewshub.co.ke