What does NHIF cover? Here are the answers [updated]

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?

Well, it depends on your cover 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
  • Radiotherapy
  • 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.

Here 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.

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

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.

Summary

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.

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