Here’s what your NHIF card covers
A client displays a NHIF card.
Michael Kinyanjui had to pay cash for his surgery after NHIF turned down his request, even though he remitted his monthly subscriptions on time.
“You know, [NHIF] has to come clean on what they are covering and what they are not. We are not going to be paying Sh1,700 monthly, yet they do not come to my rescue at [my] time of need,” he tweeted.
“Out of Sh298,000 hospital bill, all they could pay was Sh12,000 and this was only for hospital bed for which they paid Sh4,000 per night. This is a joke.”
In the Twitter thread, Nancy Muoki wrote that NHIF claims to work with public hospitals but the facilities are not well equipped.
“I went for a malaria test in one of the facilities in Kisumu, I was [sent] to a private laboratory that did not accept the card. At the hospital, most of the drugs were out of stock, I had to use cash to buy medicine outside,” she wrote.
“Even simple tests like a computerised tomography (CT), you are told that the machine is not working. In some private hospitals, they are not accepting the card. Why am I paying my Sh500 every month?”
NHIF came up with two contract suggestions for the health providers – comprehensive and non-comprehensive. All public and some mission and faith-based hospitals are under the comprehensive contract, while high-end private hospitals are under the non- comprehensive contract.
High-end hospitals fall under non-comprehensive (group C). In this category, NHIF pays a daily fixed rate. The insurer pays Sh4,000. The patient bears the difference between this rebate and the hospital bill, either individually or through another insurance provider. For instance, at a high-end private hospital that charges Sh11,500 per night for a standard room, NHIF will cover only Sh4,000 and the patient will have to pay the rest.
Faith-based hospitals
In contract B, mostly for mission and faith-based hospitals, some fall under comprehensive and others under non-comprehensive. Besides paying for a bed and all other services, NHIF normally co- pays for certain major surgical cases. This means a patient pays for some surgical operations. Hospitals under contract A include all government and public ones, where NHIF covers the full bill. A patient walks in with the card and walks out without paying anything.
But many Kenyans want to know why such contracting decisions were made, yet many public hospitals are not well equipped. “We had many complaints about [NHIF] remitting so much money to private hospitals. We listened and standardised the refunds in all hospitals and that’s how we came up with the contracts,” said NHIF chief executive officer Peter Kamunyo, adding that they engaged hospitals on the packages and most of them, especially private ones, did not like them and they picked the non-comprehensive contracts.
For an organisation with a fairly dark past, and above which a dark, ominous cloud still hangs, the turnaround has not gone unnoticed by many Kenyans. “On public hospitals, we agreed with the hospitals on the package that they charge on every service and patients should not pay anything when they are seeking services,” Dr Kamunyo said. “In case of an additional charge, then the hospital has to seek pre-authorisation from [NHIF] before the service is offered. The high-end hospitals did not like our packages. So the only agreement we have with [them] is to pay rebate (bed) and the patient settles the bill. If you decide to go to the hospitals, you will foot your bill.”
Besides rebates, he said, there are specialised services, including dialysis, that NHIF reimburses at the same rate as public hospitals. “On this, we agreed and we refund standardised amounts in all facilities,” Dr Kamunyo said.
“If there is any achievement we have managed in the past year, it is standardising the rates across all health providers. Claims payments are standardised. And public hospitals are benefitting more. This is why some hospitals opted to go alone and not to use the [NHIF] card to settle their bills. [The] NHIF card only pays for rebates, which also cut across all health facilities. From the business model of some hospitals, the infrastructure, and certain hospitals feel NHIF packages are not for them. It is just fair for them.”
For instance, at level 6 hospitals, including Aga Khan, Kenyatta National Hospital and Nairobi Hospital (KNH), the rebate per night is Sh4,000. “We don’t pay for any service in these hospitals unless it is public. Public hospitals are now leading in the reimbursement of claims. Nakuru Level Five Hospital is the number one hospital with the highest number of claims,” he said.
But Kenyans are not happy with NHIF services, as most of them subscribe monthly but must pay from their own pockets for some of the services they need. Their cards only cover the bed even though those in formal employment remit as much as Sh1,700 monthly and those in informal settlement Sh500.
Cancer treatment
Millicent Rehema, a cervical cancer patient, goes for radiotherapy sessions at KNH once a week. NHIF covers 20 sessions of radiotherapy, amounting to Sh72,000, and two brachytherapy cycles at Sh40,000 each and up to three cycles under the enhanced scheme. Even with the sessions covered, one must seek authorisation from NHIF before the hospital starts treatment. The specialist must fill out a form specifying the therapy to be administered, total sessions needed and medicines to be given.
But without a prior alert to NHIF, pre-authorisation may take long, even weeks, depending on how the hospital fast-tracks it. Even if the authorisation is given, patients may find the equipment broken down and have to seek services in private facilities and pay cash or wait for even up to a year for it to be repaired.
Last year, NHIF introduced enhanced benefits that saw patients with chronic diseases get better deals, seeking treatment for diseases like cancer at almost no extra cost. With the new benefits, the insurer pays for chemotherapy and radiotherapy for many needy patients. But at facilities with the services, such as Moi Teaching and Referral Hospital in Eldoret, some patients have complained that the cover does not include post-treatment services.
At many hospitals, even with the comprehensive contract, many patients still must first seek pre-authorisation from NHIF. That involves doctors filling out a form specifying whether they require chemotherapy or radiotherapy, the sessions needed, and any other drugs required.
Last week, cancer patient organisations asked NHIF to allow other hospitals, including faith-based and private, to treat cancer patients under the insurer’s medical cover. The Kenya Network of Cancer Organisations and the Non-Communicable Diseases Alliance Kenya said public facilities are not adequately equipped to solely provide healthcare for a rapidly rising number of patients.
