The National Hospital Insurance Fund (NHIF) is a Kenyan government-run health insurance scheme that offers financial assistance for medical bills. The amount of money that NHIF coverage will pay for specific medical procedures and treatments is limited.
These limits are established to guarantee that NHIF coverage is offered to as many people as feasible while also preventing system misuse.
In this article, we summarize the various NHIF coverage limits for both inpatient and outpatient medical treatments.
NHIF Cover Limits On Outpatient Services
Outpatient treatments covered by the NHIF include consultation costs, physiotherapy services, drug dispensing, laboratory examinations, wellness and counseling, health education, and immunization.
As long as you attend a certified hospital, there are usually no NHIF Supa cover limits for outpatient services.
Except for a few exclusions, the increased NHIF covers the whole cost of outpatient services.
NHIF Cover Limits On Inpatient Services
Bed charges, consultation, nursing care, medication, surgery, physiotherapy, laboratory tests, expert consultation, and accompanying treatment are also covered by the insurer.
Accident fractures and blood transfusion procedures are also covered.
The following are the applicable limits (bed charges):
- Low-cost government hospitals start at Kes1,200.00 per day.
- Private hospitals with high costs: The highest coverage is Kes4,000 per day.
Other service limitations are determined by the hospital categorization.
NHIF Civil Servants personnel coverage
This limits are for both inpatient and outpatient services. In some job groupings, public workers have restricted coverage for both inpatient and outpatient services.
| Job group | Outpatient (Kes) | Inpatient (Kes) |
| 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 |
NHIF Cover Limits On Maternity Care Services
The National Health Insurance Fund (NHIF) covers both regular delivery and C-sections in public hospitals as well as the majority of private institutions.
The coverage also includes prenatal care services and has the following limitations:
- Normal child delivery: Kes10,000 and below
- Caesarean section: Kes30,000 and below
Linda Mama receives a significant level of NHIF maternity healthcare coverage, with NHIF covering the entire cost.
NHIF Cover Limits On Cancer (Oncology Package)
Unlike in the past, the NHIF now covers a wide range of cancer therapies and has helped Kenyans from all walks of life gain access to crucial care.
In fact, NHIF is now evaluating its cancer care plan in the hopes of covering the entire cost of chemotherapy and radiotherapy in the near future.
Having stated that, the amount payable is now limited as follows:
1. Radiation Therapy
Under Supa Cover, NHIF pays for a maximum of 20 radiation sessions at Kes3,600 each session or a weekly maximum of Kes18,000 in government-owned facilities such as MTRH (Moi Teaching & Referral Hospital), KNH (Kenyatta National Hospital) and Kenyatta University Referral Hospital.
Some of the best private hospitals have slightly greater restrictions. For example, the limit for first-line chemotherapy at this level of hospital is Kes25,000 per session (maximum is 6 chemo sessions).
The cap for serious cases is Kes150, 000 per session (4 sessions maximum).
Finally, the cover pays for two Brachy-therapy sessions at Kes40,000 each.
2. Diagnostic Procedures
Advanced diagnostics are also covered, however there are still restrictions, particularly in high-cost hospitals.
The scheme, for example, pays up to Kes69,500 for a Piston Emission Tomography scan at the Aga Khan Hospital.
3. Cancer Clinics
The rewards for NHIF members attending oncology clinics range from Kes25,000 to Kes150,000 every cycle (But not beyond 24 sessions annually).
NHIF Cover Limits On Chronic Diseases
Aside from cancer, the present NHIF program also covers diabetes, hypertension, and renal failure (kidney failure).
The highest boundaries of the cover are as follows.
- Maximum coverage for radiology services is Kes18,000
- Monthly clinic check-up is Kes5,000 maximum
- Kidney transplants: The maximum amount is Kes500,000
- Kidney/renal dialysis: The insurance covers up to Kes9,500 each session (2 times per week)
NHIF Cover Limits On Imaging (Radiology Package)
Most hospitals provide basic ultrasound and X-ray services as part of their outpatient and inpatient medical care, whereas CT scans and MRI are available through contracted facilities.
The scans are also covered via the inter-hospital referral system, albeit you may need NHIF preauthorization to qualify.
The limits are as follows;
- CT scans might cost up to Kes8,000
- Up to Kes15,000 for an MRI scan
- Up to Kes3,000 for ultra sound
NHIF Cover Limits On Surgeries
Surgeries Major, minor, and specialist surgery packages are capped at an average of Kes500,000 per person, depending on the hospital level and the procedure you’re having.
Overall, the limits apply as follows;
- Minor Surgical Procedures: Coverage ranges from Kes10,000 to Kes30,000
- Intermediate Surgical Procedures: Kes40,000 – Kes80,000 are covered by the plan.
- Benefits for major surgical procedures are set at Kes130,000
- NHIF covers up to Kes500,000 for specialized surgical procedures for registered NHIF recipients.
NHIF Cover Limits On Dental Treatment
The NHIF Dental Coverage includes dental consultations, root canals, dental X-rays, dentures, orthodontics, filling costs, and extractions (including surgical extractions).
Dental anesthesia and operating room costs are also covered. The provided limits are per service but will not exceed Kes50,000 per household per year.
NHIF Cover Limits On Optical Services
The yearly limit for optical care services obtained from authorized hospitals is Kes40,000 for all Job Groups for civil servants.
Services That Are Not Covered By The NHIF
There are various exclusions in the benefit package, which means you cannot receive payment for them. Among these include, but are not limited to:
- Cosmetic or beauty treatments, as well as cosmetic surgery, are available.
- Massage (unless if medically certified in the course of physiotherapy because of an accident or related disorders) (except where medically certified in the course of physiotherapy because of an accident or related illnesses).
- Any therapies obtained from non-accredited facilities or unapproved referrals.
- Expenses reimbursable through other insurance plans.
- Treatment provided by acupuncturists, chiropractors, and herbalists, as well as fees incurred as a result of therapies received from nature cure clinics and similar businesses.
- Vaccines, but KEPI vaccines, anti-rabies vaccine, Rota virus vaccine, anti-snake venom, and Yellow Fever vaccine (NHIF liaises with the health ministry and county governments in providing these Vaccines).
- Treatments for obesity.
- Charges that are recoverable under the WIBA (Work Injury Benefits Act) or similar medical plans.
- Any additional treatments/care that are prohibited under the NHIF contracts made with businesses.
What You Should Know About The Different NHIF Schemes
You can readily update your dependents’ information by visiting any NHIF office, as well as Huduma centers.
If you are scheduled to have more than two radiography sessions each week, you should get NHIF pre-authorization so that the extra expense is covered.
In severe circumstances, the facility may request that you receive NHIF pre-authorization from your insurer before being cleared. A full medical report, completed NHIF Pre-authorization form, Pro-forma invoice, National ID card, and a scanned copy of your NHIF card will be required in this scenario.
Conclusion
In summary the NHIF insurance limits differ by hospital and employment group (for civil personnel), you should use the preceding analysis as a guide. However, it must be noted that the rates above are subject to change and you should consult beforehand.
The best approach to find out how much the insurer will pay for you is to ask the medical facility or call NHIF directly at (020) 2723246.
