NHIF works by pooling resources from its membership to pay for treatment for those who fall sick.
NHIF generates its revenue from its monthly membership contribution where a self-employed person contributes Ksh 500 while those in formal employment make a monthly payment of Ksh 150 to Ksh 1700 which is deducted from their salary and remitted to NHIF by their employer.
Once the card is active, members can then seek treatment services in any accredited hospital where NHIF foots the hospital bill.
How NHIF outpatient works
The outpatient service for NHIF super cover works by members first choosing their preferred hospitals.
NHIF then pays the hospital that a member has selected, money upfront to cater for his treatment. This is what is commonly known as capitation.
At the point of treatment, the hospital notifies NHIF via the e-claim system that a member has come to seek outpatient services.
The patient is treated and discharged but no claim is lodged since the hospital has already been paid up front.
How NHIF Inpatient works
A member visits a hospital for treatment and a doctor reviews his case and depending on the severity of the case recommends admission.
The hospital notifies NHIF via a system that a member has been admitted in their facility.
The patient is given the necessary treatment, gets well and then discharged.
The hospital then lodges a claim with NHIF which is paid as rebate or bed charges. This is a daily rate that covers everything from admission fee, lab tests, meals, drugs, doctor’s fee and nursing care.
For members under the supa cover scheme, we recommend admission in a comprehensive facility so that you do not have to pay any extra amount.
How NHIF preauthorization works
Member visits a hospital in need of treatment.
A doctor reviews his case and recommends a specialized service such as surgery, dialysis, CT scan e.tc
A preauthorization or request for approval to conduct the service is sent online by the hospital staff to NHIF, attaching all the necessary documents.
A personnel with medical experience in NHIF, reviews the documents and approves the amount according to the cover limit of the package or rejects the request with reasons.
Once a request has been approved or rejected, a text message will be sent to the phone number registered with NHIF stating the approval status.
Some of the common reasons that we have found for rejection of NHIF preauthorization requests are insufficient payments and incomplete attachments.
The hospital then invoices NHIF the amount that was approved.
How NHIF pays hospitals
There are three ways that NHIF pays hospitals
- Capitation process
This is where NHIF pays a hospital upfront at the beginning of every quarter. The amount ranges from Ksh 250 to Ksh 350 (depending on the level of hospital) for every member who has chosen that facility.
For example, If 10,000 members have selected a level 3 hospital; NHIF will pay that hospital a total of Ksh 2,500,000 every three months.
The above process borrows from the insurance model where you pool resources from a large number of people to protect a few who will get sick.
Let’s take a typical scenario using the above example; imagine that 10% of the 10,000 members that have selected your hospital have become sick within a period of 3 months. i.e. 1,000 patients.
Each incurs an average cost of Ksh 2,000 as treatment fee and drugs dispensation. This translates to a treatment cost of Ksh 2,000,000. Your gross profit will be Ksh 500,000.