Economy

NHIF contributors to wait longer for improved benefits

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NHIF headquarters: Statutory health insurer remains fuzzy on details even as it begins to collect new fees. PHOTO | FILE

Contributors to the National Hospital Insurance Fund (NHIF) have to wait longer to access enhanced medical services after the public health insurer said the higher fees it began collecting this month will be used to build a capitation pool from which to pay hospital bills.

News of the impending delay in accessing the benefits came even as the insurer remained tight-lipped on whether contributors will be allowed to use their NHIF cover to access medical services in high-end private hospitals such as Nairobi Hospital and Karen.

The NHIF, which started deducting higher premiums last month, said it was discussing capitation rates with the hospitals.

The insurer is also yet to determine by how much it will increase its in-patient rebate amount that currently stands at Sh1,900, and which mainly goes to settle the cost of a patient’s hospital bed.

Yesterday, the NHIF said it will in the coming weeks invite contributors and their dependants to pick a preferred hospital from a list of approximately 1,600 health service providers.

The NHIF, which has 4.5 million members, has until now been providing in-patient cover for its contributors but the new rates are meant to extend its coverage to outpatient services.

“The contributions we began collecting last month will be used to pay hospitals a monthly capitation fee depending on the number of contributors, who select a particular institution,” Simon ole Kirgotty, the fund’s CEO, said.

READ: Employers want new NHIF rates pegged on basic pay

Mr Kirgotty said the national programme would be rolled out in June when the NHIF would start paying hospitals before they treat contributors.

The uncertainty over what benefits the contributors are entitled to has been compounded by the near absence of public sensitisation on their rights under the new regime — a gap that could create a backlash in the event users’ expectations are not met.

Contributors remain in the dark as to where and when they could access the much-touted enhanced services despite having started paying higher premiums to the new scheme last month. 

On February 13, the NHIF gazetted rules that require Kenyan workers earning between Sh50,000 and Sh59,999 to contribute Sh1,200 to the scheme every month and the self-employed Sh500 a month up from Sh160.

Those earning Sh5,999 and below are required to pay in Sh150 while the top earners with a monthly pay of more than Sh100,000 must pay in  Sh1,700, a 431 per cent increment.

Workers and employers have been strongly opposed to the increases in monthly premiums, questioning the NHIF’s corrupt past and its capacity to administer the huge scheme.

The NHIF reckons that review of monthly premiums was necessary for the planned improvement of services. The introduction of an out-patient cover has been the fund’s major selling point during the transition.

The NHIF contributors are currently entitled to an in-patient cover (whereby the public insurer pays the Sh1,900 rebate) and maternity cover worth Sh6,000 and Sh18,000 for normal and C-section deliveries respectively.

Civil servants and members of the disciplined forces are, however, covered for outpatient services through a special scheme that was launched in 2012 but was immediately hit by a mega scandal involving selection of providers.

The new out-patient cover will offer services like general consultation, treatment of sexually transmitted diseases, renal dialysis, X-rays and minor surgical procedures.

“The outpatient cover will not have a limit like insurance firms; it will offer comprehensive cover to all deserving patients no matter how many times they fall sick,” said Margaret Nzwii, the acting general manager for operations at the NHIF.

The list of hospitals, which members will “by the end of the month” be invited to pick from (for both outpatient and inpatient services), has been divided into three categories, the NHIF said.

Category One has public facilities such as Kenyatta National Hospital in Nairobi and Eldoret’s Moi Teaching and Referral Hospital while faith-based health service providers such as St Mary’s Mission Hospital in Nairobi are in Category Two.

“When a patient visits either a public or faith-based hospital, they will simply walk in and walk out without incurring any extra expense whatsoever,” said Ms Nzwii.

The NHIF had previously indicated that those paying the highest premiums (Sh1,700 per month) will have their annual benefits capped at Sh1.2 million while those paying the least will have a Sh30,000 limit.

In the third category are high and low-end private hospitals, which most Kenyans prefer because they are better equipped and well-managed.

The NHIF had initially planned to restrict access to outpatient, inpatient and maternity services to public hospitals and low-cost private hospitals but that now appears to have been shelved.

This limitation would have meant that private sector employees who are already accessing quality medical care from private hospitals would continue to depend on employer-sponsored schemes, with the higher premiums adding to labour costs without the benefit of a healthier workforce.

The statutory fund’s argument has been that locking out high-end private hospitals like Aga Khan, MP Shah, Mater and Karen was purely to avoid the higher charges.

The NHIF’s cover for civil servants and the disciplined forces, which is being used as a reference for the new plan, does not exclude high-cost facilities.

“We are in talks with the high-end private hospitals about their ability to provide out-patient services,” Ms Nzwii. “We shall be presenting them with our proposed rates offering them a chance to sign up. It is a willing buyer and willing seller scenario, meaning only those high-end hospitals that find our rates sustainable will sign up.”

The new scheme will cover the principal member, their spouse and an unlimited number of children aged up to 18 and 23 if they are still in college.

Each family member will independently choose their preferred hospital, with those who live away from the principal member being free to pick their own facility. In the event of an emergency, a member will be treated at the nearest available facility with the expense later being charged to the hospital the member initially chose.

The NHIF will also come up with a list of specialised hospitals where a patient can be referred in case their hospital of choice lacks the capacity to handle them.

This list, the fund says, will only be shared with the 1,600 hospitals in the programme to deter patients from attempting to influence the choice of the facility they are sent to.