NHIF takes up higher portion of contributors’ treatment fees

The cost of managing chronic diseases such as diabetes and kidney failure is expected to come down significantly following a decision by the National Hospital Insurance Fund (NHIF) to more than double the amount of money the fund can pay for treatment.

A notice published in the Kenya Gazette also shows that the NHIF has increased medical cover for inpatient services in both public and private hospitals in a move that effectively lowers the cost of accessing medical care for thousands of contributors.

The legal notice shows that the NHIF will pay for kidney dialysis up to a limit of Sh10,000 per session from the current Sh2,500 while kidney transplants are now covered to the tune of Sh500,000 from Sh200,000.

Geoffrey Mwangi, the acting NHIF chief executive, said the new rates have been set following negotiations and agreements with hospitals.

The rates apply to both outpatient and inpatient services in more than 2,000 health centres and top hospitals such as Aga Khan and Nairobi Hospital, where a dialysis session costs about Sh10,000 and consultation fees are fixed at between Sh1,000 and Sh2,000.

Kenyatta National Hospital (KNH), the country’s main referral facility, charges Sh5,000 for a session of kidney dialysis — meaning patients have been financing half the cost of treatment from their own pockets.

Cancer patients have also got a relief from the latest price reviews, with the increase of cover for chemotherapy to Sh25,000 per session and to a maximum of Sh18,000 for radiology.

KNH charges Sh5,000 per session of radiotherapy while private hospitals like MP Shah, Nairobi Hospital and Aga Khan charge about Sh10,000, meaning the entire cost is covered.

Expectant mothers have also won big with the increase in maternity cover to Sh10,000 from Sh6,000 for normal delivery while a C-section delivery is covered up to Sh30,000 from Sh18,000.

The notice also shows that diagnostics test, MRI, is now covered up to Sh15,000 per session while CT-scan is capped at Sh8,000.

The enhanced cover comes as a big relief for low-income households who are often hard-pressed to raise cash for treatment of chronic diseases in private hospitals.

The NHIF has also gazetted new inpatient rebates, doubling the cover for bed costs, meals and med care.

The public insurer will now pay a minimum of Sh1,200 per night, up from Sh600 for members admitted to public or faith-based hospitals and up to Sh4,000 a night for those admitted to top private facilities like Aga Khan and Nairobi Hospital, or double the previous cover.

Mr Mwangi reckons that the enhanced rebates, in addition to outpatient cover introduced last July, have put Kenya on the path to achieving universal healthcare.

The increments have narrowed the cost gaps between what hospitals charge to admit patients and what the public insurer pays in rebates, a relief for thousands of patients seeking care in well-equipped and mostly private facilities.

Most patients have in the past had to dig into their pockets to top up the NHIF rebates that fell short of what the hospitals charged.

READ: NHIF targets Sh3bn monthly collection from June

Aga Khan and Nairobi Hospital, for instance, charge their inpatients Sh9,500 per day in the general wards.

The new rebate of Sh4,000 now means the top-up amount is down to Sh5,500 compared to Sh7,600 previously, saving them Sh2,100.

Hospitals are divided into three categories for inpatient care.

Public facilities like KNH are in Category A, where users do not incur any expenses if they seek medical attention there. Similarly, patients do not incur expenses in faith-based health service providers in Category B.

Medical attention from private hospitals (Category C) — that are popular with most Kenyans because they are better equipped — require extra cash to top up the NHIF rebates.

KNH now has a rebate of Sh4,000 a night, up from Sh2,400 paid for the general wards, while those receiving treatment at Eldoret’s Moi Teaching and Referral Hospital are covered to the tune of Sh3,500 a night.

The NHIF has, however, suffered serious setbacks with the rollout of the outpatient cover introduced last July after the fund failed to reach a capitation deal with top private hospitals.

The lack of a deal means contributors remain confined to medical care from public hospitals and small private facilities that have agreed to the lower capitations. This is despite an increase in workers’ monthly contributions to the fund from Sh320 to between Sh500 and Sh1,700 in April based on their pay scale with the promise of enhanced outpatient benefits in both public and private hospitals.

READ: NHIF contributors still locked out of major hospitals

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Top private hospitals, which are better staffed and equipped, have rejected the Sh1,200 that the NHIF has offered to pay as annual fee (capitation) for every beneficiary, dismissing it as too little.

“None of our members has accepted the outpatient scheme,” said Kanyenje Gakombe, the chairman of Kenya Associations of Hospitals (KAH), which represents 15 top hospitals, including Nairobi Hospital, Aga Khan, Mater, Kijabe, MP Shah and Gertrude’s. 

This has left the NHIF’s private sector contributors with a small number of bottom and middle-level hospitals, most of which offer low quality services.

Civil servants and members of the disciplined forces, however, continue to enjoy inpatient and outpatient services at both public and top private hospitals, a development that has sparked an outcry from private sector workers.

Under the scheme, the national health insurer pays Sh1,200 annually to a facility that the contributor and his family has chosen and where they are entitled to services without cost limits.

Besides the top non-government hospitals, private sector workers cannot access outpatient healthcare at key public facilities such as Moi Teaching and Referral Hospital, Coast Provincial General Hospital (Mombasa) and KNH.

Workers’ monthly contributions to the NHIF in April increased from Sh320 to a graduated scale that is dependent on monthly pay.

Contributors earning between Sh50,000 and Sh59,999 in April last year started remitting Sh1,200 to the enhanced benefits scheme while the self-employed are paying Sh500, up from Sh160 a month.

Workers earning Sh5,999 and below are paying Sh150 to the fund every month while those earning Sh100,000 and above remit the highest amount of Sh1,700.