NHIF cuts back outpatient benefits

The National Hospital Insurance Fund (NHIF) has released new guidelines that have significantly reduced contributors’ benefits for outpatient treatment at authorised clinics.

The contributors are now entitled to only four outpatient visits per year, the NHIF said, leaving them to the pain of out-of-pocket spending whenever they fall sick.

Civil servants and those in managed schemes whose employers make additional monthly contributions to the scheme have, however, been spared the cut and will continue to enjoy unlimited outpatient services of at least Sh100,000.

Under the new rules, once a family (under national scheme) exceeds the maximum visits per card a year (four) they will be forced to pay for all outpatient services in cash.

This means that the larger the family, the less services will be available for each member of the family. Young children who are covered as beneficiaries under a principal member, the elderly, accident victims who are likely to require additional care will be the most affected by the new regulations that NHIF said are meant to curb fraudulent claims.

“This is one way of dealing with fraud since a member would have control over the number of visits, which are fixed-for-service, meaning NHIF would only pay a facility the actual cost incurred and not the initial Sh1,500 cap for all facilities per year,” NHIF chief executive Geoffrey Mwangi said.

“This will be more beneficial to families where both partners have individual cards, meaning they will be entitled to eight visits.”

The announcement came a day after the fund announced that members would no longer be restricted to getting treatment from hospitals they had initially selected, but in any NHIF-contracted facility offering outpatient services.

Mr Mwangi said the outpatient package has been enhanced to cover ultrasound – a painless procedure that produces images of internal body organs using sound waves. The package also covers consultation in low-end facilities, lab tests and cheap drugs. Imaging studies - MRI and CT Scans – are also included.

NHIF has also promised to roll out an outpatient chronic package to cater for contributors with terminal and lifestyle diseases (like diabetes and high blood pressure).

It has, however, left out basic surgical follow-up visits for patients with fractures that require three to four visits a month or X-rays for healing assessment.

“Before, the providers were left to determine the number of patient visitation but without gate-keeping mechanisms there are risks of fraud,” said Mr Mwangi.

So far, only 1,000 service providers have signed up for the enhanced outpatient package – out of the 2,500 accredited facilities.

Kenya Association of Private Hospitals (KAPH) treasurer George Rae said they have no option but to sign the agreement so as not to completely lock out the needy from accessing care.

“We have a desire to achieve limitless access to services, but this is limited. We would want to engage more and expand that if we are to achieve universal healthcare,” said Dr Rae.

“It would be limiting especially to those with children who could visit the hospital even 10 times a month. People don’t have money every time in their pockets and diseases do not warn.”

Private insurance companies have been putting a cash limit on outpatient services.

KAPH is concerned that the enhanced package would affect the quality of service in the long run with underutilization of outpatient services by the poor, a ticking time bomb as outpatient services are likely to shoot due to late diagnosis.