The National Hospital Insurance Fund, NHIF
The National Hospital Insurance Fund, NHIF

The National Hospital Insurance Fund, NHIF, has introduced a raft of measures on management of the fund. In the new changes, new members will have to wait for a period of three months up from the current two months. The number of spouses has been capped at one with only five kids (dependants) benefiting. The new changes took effect on January 1, 2020.

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Here is the NHIF circular dated January 7, 2020:

“In order to align the organization towards attainment of sustainable Universal Health
Coverage and for purpose of enhancing member retention, the Special Full Board Meeting of 17th December 2019 resolved that the following changes be effected in Member Management Module with effect from 1 January 2020:

  • Revision of the waiting period for new voluntary National Scheme members from current 60 days to 90 days and to introduce a 1 year (12 months) upfront payment, payable within the waiting period while observing the due dates, before one can eligible for any
    of the benefits.
  • Penalty on defaulting beneficiaries to stand at 50% of the monthly contribution for each month paid late, up to 11 months, coupled with requirement to pay for one year in advance and a restriction of 30 days before being eligible for benefits.
  • In case of default for 12 months and above, the affected member will start payment afresh and be eligible for benefits after 90 days from the date of resumption of payment in addition to a 1 (one) year (12 months) upfront payment, payable within the waiting period while observing due dates otherwise rule number 2) above, will also apply.
  • For Voluntary Members access to maternity benefit be restricted to 6-months post card maturity for principal members or spouse declared at the point of registration.
  • For both Maternity and Specialized Services, any dependent declared after initial registration shall be subjected to a 6-month waiting period after such declaration with exception of newborns who shall be considered eligible for benefit provided they are declared within 6 months from the date of birth.
  • For medical inpatient and medical outpatient additional dependents shall be eligible for benefit after 30 days waiting period. This waiting period of 30 days will also apply in case of change of spouse.
  • Eligibility to access to Specialized Services shall be restricted to 6-month wating period following card maturity for new members, while for defaulters, there shall be payment of all penalties and 1-year upfront payment of contributions coupled with a 30-day waiting period thereafter.
  • For National Scheme members, number of dependents per card to be limited to a maximum of (1) one spouse and (5) five children. For Managed scheme it will be capped at M+6 and M+1 for normal and retiree schemes respectively.

Additional dependents can be included subject to payment of additional premiums to be communicated after actuarial valuation.

SPARED MEMBERS

The above changes on Member Management should exempt the following Government funded programs that targets vulnerable groups:

  • ¬†Health Insurance Subsidy Program
  • Free Maternity Program (Linda Mama)
  • Elderly Persons with Severe Disabilities
  • ¬†Inua Jamii Program

Please communicate these changes to the declared Health Care providers in your
jurisdiction and explain to them that the same will be observed when processing claims.”

Kindly note that specialized services, in this context, means all services except for medical in-patient and medical out-patient.