Lower cadre teachers may soon be forced to pay more to access medical services in private rural hospitals following the failure of their insurance administrator to disburse funds.
Medical Administrators Kenya Limited (MAKL), which oversees the medical scheme for teachers in grades B5 to D2, is yet to pay rural hospital operators Sh6.01 billion in outstanding claims running as far back as July last year.
The healthcare operators under the Rural Private Hospitals Association of Kenya (Rupha) have issued a seven-day notice to MAKL to settle the bill or teachers will be compelled to top up the co-pay amount.
“Failure to comply with this notice will leave us with no choice but to request the beneficiaries under the medical scheme to make out-of-pocket payments to access necessary healthcare services,” said Rupha chairman Brian Lishenga in a letter to the Teachers Service Commission (TSC) chief executive Nancy Macharia.
It is also addressed to Minet Kenya Insurance Brokers and the Kenya Secondary School Heads Association.
Teachers are charged a Sh50 co-payment on a hospital visit, but Rupha is warning to increase this to Sh500 to mitigate costs.
A co-payment is a fixed amount that a healthcare beneficiary pays for medical services, with the balance covered by the insurer.
Under the medical scheme, outpatient cover for teachers ranges between Sh100,000 and Sh250,000 while the inpatient package ranges between Sh750,000 and Sh1.8 million and maternity is between Sh100,000 and Sh150,000.
The TSC maintains it has disbursed money for the Sh55 billion teachers' medical scheme under the three-year contract.
Dr Lishenga notes that the delayed settlement of claims has caused severe financial hardships for the more than 350 healthcare centres in rural and urban underserved populations such as Kangemi, Kayole in Nairobi and Kisauni in Mombasa.
The contract with the MAKL stipulates that claims will be paid within 60 days.
“No single facility has received any payment over the past eight months which is in total breach of contract,” he said.
NHIF requests
The Sh6.01 billion bill owed in the period to May 31 includes Sh3.76 billion outpatient claims, Sh1.58 billion inpatient debt, maternity (243 million), dental (158 million) and optical (Sh260 million) claims.
The administration of the medical scheme for higher cadre teachers in Grades D3 to D5 that includes deputy, senior and chief principals is handled by Minet Kenya Insurance Brokers.
The TSC awarded Minet the tender in November 2022 for three years despite the many requests from teachers to be insured by the National Health Insurance Fund.
