NHIF comprehensive cover


A comprehensive cover is a managed scheme where an institution has negotiated with NHIF to offer an enhanced medical scheme to its employees.

Just like how a company can contract a private insurance such as jubilee to offer a medical scheme to its employees, is the same way an institution can contract NHIF to offer the same but at an extra cost.

It’s key to note that an employer( for example the government in the case of civil servants) chips in an extra amount for its employees, up and above what they are deducted from their payslips as statutory deductions thus qualifying to get a comprehensive cover.

Who qualifies for NHIF comprehensive cover?

  • Civil servants who are employees of the National government
  • The National Police and Kenya Prison Services,
  • Government Parastatals
  • Some county government employees
  • Former MP’s.
  • Companies that have contracted NHIF to offer a comprehensive medical scheme to its employees

Types of NHIF comprehensive cover

  1. Fixed fee for service(FFFS)- This is where a fixed amount is paid to a hospital every time a member is treated.
  2. Fee for service(FFS)-This is where a hospital invoices NHIF the cost of treatment incurred by a member.

Advantages

  • Walk in and walk out without paying a dime
  • One does not need to choose a hospital thus not limited to a specific hospital

Disadvantages

  • The fee for service option has a limit.Therefore, if you exhaust your limit within the financial year you will have to pay out of pocket.
  • You can only cover a maximum of 6 dependents i.e. your spouse and 5 children. If you want to add more beneficiaries to your card, you have to chip in some extra amount.
READ  NHIF cover limits

Benefit packages under the NHIF comprehensive

Under the comprehensive cover, members can access various benefit packages namely;

  1. Outpatient package-This covers;
  • General consultation
  • Diagnosis and treatment
  • Prescribed laboratory tests
  •  X-ray and ultra-sound imaging services
  • Prescribed drug administration and dispensing
  • Physiotherapy
  • Occupational therapy
  • Management of chronic ailments such as diabetes, asthma, hypertension
  1. Inpatient package-Under inpatient the following services are offered
  • Triage and pre-admission consultation and reviews
  • Hospital accommodation charges, meals and nursing care
  • Bedside services including physiotherapy, occupational therapy, oxygen supply, and medical consumables.
  • Laboratory investigations
  • Post discharge medication
  1. Maternity cover-Mothers with the NHIF comprehensive cover get the following services;
  • Consultation  with a gynecologist ;
  • Prescribed laboratory tests;
  • Labor, delivery, aftercare for the mother together with the newborn
  • Post discharge medication
  • Midwifery and services pertaining to childbirth by ways of normal delivery,
  • Caesarean section as necessitated
  • Ward care and accommodations
  • General nursing care
  • Lactation consultations
  • Meals and special diets
  • Prescribed drugs and medicines
  1. Radiology-This covers;
  • Medical consultation to determine the appropriate imaging examinations needed.
  • MRI and CT Scans diagnostic imaging services
  • Reviewing and interpretation of radiological images and giving the diagnostic opinion
  1. Oncology-The following services are administered under this cover for purposes of cancer treatment;
  • Chemotherapy
  • Radiotherapy
  • Brachytherapy
  • Routine laboratory investigations
  • Anti-cancer (cytotoxic) drugs –oral and injectable
  • Hormonal therapy
  • Support medication
  • Pet CT Scan
  1. Dialysis-The following services are covered under the dialysis package
  • Specialists reviews
  • Cost of the catheter
  • Catheter insertion and removal
  • Nursing and dialysis services
  • Prescribed lab tests
  • Dispensed medications
  • Pre-dialysis, intra-dialysis sessions and post-dialysis care
  1. Surgical package-This package under the NHIF comprehensive cover entails;
  • Pre-operative admission and care
  • Minor, major and specialized surgical procedures including transplants
  • Intra- Operative and post-operative care and medication
  1. Drugs and substance abuse –Under this package the services below are covered
  • Detoxification
  • Rehabilitation
  • Aftercare support
  1. Mental and behavioral health-This package covers the treatment of
  • Common mental disorders including depression and anxiety.
  • Severe mental disorders including psychosis, schizophrenia and bipolar disorder
  • Neurological disorders such as epilepsy and dementia
  1. Foreign treatment
READ  How NHIF works in Kenya

This covers any medical and surgical treatment procedures not locally available in Kenya.

To be eligible for overseas treatment ,you must obtain clearance from the Ministry of Health.

  1. Emergency road and air evacuation

The Kenya Red Cross is contracted by NHIF to offer Ambulance services for transportation and transfer of a sick member or dependant for treatment to the nearest NHIF Accredited Health Facility.

Emergency Air Rescue is also available for transportation and transfer of an injured principal member of the scheme to health facilities where adequate treatment is available.  

AMREF Flying Doctors has been contracted to provide emergency air rescue services

  1. Dental package

The dental benefit package covers procedures such as orthodontics, root canal, dentures, tooth filling and extraction.

Cosmetic procedures such as teeth whitening, dental braces are not covered. This package is not offered in the NHIF super cover scheme

  1. Optical Package

Treatment of eye and visual problems are treated under this package.

A member is issued with a pair of spectacles once in two years though you are allowed to replace your lenses yearly. This package is also not offered in the NHIF supa cover scheme

How do I know if my NHIF is comprehensive?

  1. Dial *155# and follow the prompts
  2. You can sending a text message to 1550 with the format [ID {space} Your ID Number] e.g. (ID 12345678)
  3. Alternatively you can ask your HR if they have a negotiated an enhanced medical scheme with NHIF
  4. Also a quick way to know if your cover is comprehensive is if you attempt to choose a hospital, you will get a text message stating that you are not allowed to choose since your cover is comprehensive. If it allows you to choose or change a hospital it falls under the NHIF supa cover scheme
READ  NHIF registration

How much do you pay for comprehensive NHIF cover?

For an employee they will pay their usual statutory deductions as per the granulated salary scale as their employer tops up for them to be offered a comprehensive NHIF cover.

Hospitals that offer the NHIF comprehensive cover

Contract A, B and C hospitals all offer the NHIF comprehensive cover.

Contract C hospitals are high end private hospitals thus treatment and drugs are costly. If you attend this type of hospital, beware that your limit can be exhausted very fast and you may be forced to pay for yourself for future treatments.

Examples of contract C hospitals are Agakhan, Nairobi hospital, Avenue hospital, MP shah.

Visit the NHIF website to get an exhaustive list.

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