NHIF cover limits

NHIF cover limits

In the quest for achieving universal health coverage, NHIF has now standardized reimbursment rates and cost of procedures across all health care providers. The new cover limits are categorized according to whether a hospital has signed a comprehensive contract or non-comprehensive contract with NHIF.

A comprehensive facility is not allowed by law to co-charge a registered NHIF member while a non-comprehensive facility is allowed to co-charge. This means that if a member under the NHIF supa cover scheme opts to visit a non-comprehensive facility, he or she will have to top up and pay the hospital bill as NHIF will only pay a portion of it.

Visit the NHIF website to view a list of the comprehensive facilites.

National Scheme cover limits and reimbursment rates

Also known as NHIF supa cover, hospitals are reimbursed via the capitation model for outpatient services while for inpatient they are reimbursed via the rebate model also known as bed charges.

Below are the reimbursment rate and cover limits for this scheme.

Outpatient package

Level of HospitalReimbursment Rate
IIKsh 1,000
IVKsh 1,400
VKSh 1,400

Inpatient Package

Level of HospitalComprehensive facility Reimbursment RateNon-Comprehensive facility Reimbursment Rate
IIIKsh 2,000Ksh 1,600
IVKsh 3,000Ksh 1,800
VKsh 3,500Ksh 2,000
VIKsh 4,000Ksh 4,000

Maternity benefit package cover limits

Below are the NHIF maternity benefit packages cover limits for comprehensive and non-comprehensive facilities.

Comprehensive facilities

Level of hospitalNormal delivery limitsCesarean section limits
IIIKsh 10,000Ksh 30,000
IVKsh 10,000Ksh 30,000
VKsh 10,000Ksh 30,000
VIKsh 10,000Ksh 30,000

Non-comprehensive facilities

Level of hospitalNormal delivery limitsCesarean section limits
IIIRebate up to 2 nightsRebate up to 3 nights
IVRebate up to 2 nightsRebate up to 3 nights
VRebate up to 2 nightsRebate up to 3 nights
VIRebate up to 2 nightsRebate up to 3 nights

Surgical benefit package cover limits

Type of SurgeryComprehensive facility limitsNon-comprehensive facility limits
Minormaximum of Ksh 40,000Rebate for 1 day
Majormaximum of Ksh 240,000Rebate for 3 days
Specializedmaximum of Ksh 480,000maximum of Ksh 480,000 only at level IV,V and VI

Radiology benefit package cover limits

Type of imagingComprehensive facility limitNon-comprehensive facility limit
CT ScanKsh 6,000Ksh 6,000
FluoroscopyKsh 4,000
MammogramKsh 4,000
MRIKsh 9,600Ksh 9,600
Specialized UltrasoundKsh 5,000
Echo AdultKsh 5,000
Echo PaedsKsh 8,000
EEG AdultsKsh 5,000
EEG paedsKsh 8,000

READ  NHIF comprehensive cover

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