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.
Capitation only applies to the NHIF supa cover outpatient package.
Commonly known as bed charges, NHIF pays hospitals a daily fixed rate for inpatient services for members under the NHIF supa cover.
The rate is determined by the level of the hospital and whether it is comprehensive facility or not
Rebate ranges from Ksh 1,600 to Ksh 4,000 a day.
- Invoiced amount
All other benefit packages under NHIF supa cover apart from outpatient and inpatient are submitted to NHIF, for the hospital to be reimbursed the cost of treatment.
Prior to invoicing NHIF, a hospital has to seek approval from the insurance in what is commonly known as preauthorization to administer a specialized service such as surgery. The approved amount is what the hospital invoices NHIF.
Claims emanating from treating a member of a NHIF comprehensive cover are also submitted to NHIF for payment since members under this scheme are billed as per the cost of treatment.
Which hospitals do NHIF cover?
NHIF covers comprehensive and non- comprehensive hospitals.
Government public hospitals, faith based or mission hospitals and low cost private hospitals fall under comprehensive facilities.
High cost private hospitals fall under non comprehensive facilities.
There are over 5000 accredited hospitals contracted by NHIF. To view the list, visit the NHIF website.
Can I be treated without NHIF card?
NHIF has digitized their hospital system in a way that you can be identified through your fingerprints.
You do not need to carry your NHIF card for you to receive treatment. All you need to carry is your National ID.
Can I use my NHIF in any hospital?
If you are a member of a NHIF comprehensive or enhanced cover you can use your card in any hospital be it a public, faith based, low cost or high cost.
When can I change my NHIF outpatient hospital?
You can change an NHIF hospital at the beginning of every quarter i.e. January, April, July and October or just before the end of a quarter so that it is effected the following month.
How can I change my NHIF hospital by phone?
To change a hospital you can dial *155# on your phone or Login to the NHIF self-care portal.
Ensure your phone number is registered with NHIF for the process to be successful. If your number is not registered contact NHIF customer care on toll free number 0800 720 601
How many hospitals can I choose for NHIF?
You are only allowed to choose one outpatient hospital per quarter. If you are not happy with the services a hospital is offering, you have the option of changing it the next quarter.
Can NHIF refund money?
Unfortunately NHIF does not refund money incurred from cost of treatment in the event you did not notify the hospital prior to admission that you have an NHIF account.
A notification has to be done in the NHIF system within 24 hours from the point of admission. If the notification is not within the stipulated time, NHIF will not pay the hospital and definitely will not refund the money if you settle the bill.