NHIF Comprehensive Medical Cover For CIVIL SERVANTS, NATIONAL POLICE, COUNTY GOVERNMENTS, PUBLIC AND PRIVATE INSTITUTONS

Comprehensive Medical Insurance Scheme for Civil Servants Benefits Limits of liability in Kenya Shillings

In January 2012 the Government and NHIF entered into a contract to offer a unique Comprehensive Medical Insurance Cover for Civil servants through NHIF.

❖ Based on the successful implementation and administration of the scheme, NHIF agreed to provide the cover to county governments, parastatals, public and private institutions.
❖ As at November 2018 there are seventy one (71) active accounts that are accessing the enhanced medical schemes.
❖ The medical cover caters for the principal member, spouse and five declared children of up to 21 years of age and/or a maximum of twenty five (25) years of age if still in full time formal education (M+6)

NHIF Civil servants Insurance ELIGIBILITY

1. Civil servants, National police and prisons, staff under county governments, public and private institutions that have signed with NHIF.

2. Declared spouse by the principal member.

3. Declared children up to the age of 21 or 25 for a child enrolled in full time formal education

4. NB: There is no age limit for dependants with Disability (proof of registration
with the National Council for Persons with Disability will be required);

PROVISION OF COMPREHENSIVE MEDICAL COVER FOR KENGEN RETIREES

Inpatient, Outpatients, Optical, Dental, Last expense, Annual premium, Additional premium per dependent
300,000 40,000 30,000 30,000 100,000 37,528 2,900
500,000 50,000 40,000 50,000 100,000 42,524 3,000
1,000,000 100,000 40,000 50,000 100,000 65,153 4,000
1,250,000 150,000 40,000 50,000 100,000 72,159 4,100
1,500,000 200,000 40,000 50,000 100,000 79,165 4,200
1,750,000 225,000 40,000 50,000 100,000 86,170 4,500
2,000,000 250,000 40,000 50,000 100,000 96,678 4,600
2,500,000 350,000 40,000 50,000 100,000 100,181, 6,000
5,000,000 350,000 40,000 50,000 100,000 194,249, 11,000

NHIF Civil servants Insurance Benefit Package

• In and Tests for Organ Donors
• Chronic illness In and Outpatient Cover
• Renal Dialysis’s
• Emergency
• Rescue Services Road & air
• Drug & substance abuse
• Rehabilitation Package
• Maternity Package
• Radiology Services
• Overseas Treatment
• Last Expense
• Dental and Optical
• In and Outpatient Cover
• Annual Medical Check-up
• Vaccination

NHIF Government Officer Insurance Benefits

All enrolled members of the scheme can access comprehensive in-patient services in accredited GOK Health Care providers, Mission/Faith based Health care providers and in Major Private Hospitals. The list is available in

ACCESS OF BENEFITS
1. Contract A -County public Hospitals & National Government Hospitals
2. Contract B- Faith based hospitals and medium low private
3. Contract C-High cost private Hospitals(Rebate)
4. Referral for specialized services

NHIF Outpatient Coverage

The outpatient benefit package includes both curative & preventive services which comprise, but not limited to:
i. Consultation
ii. Laboratory investigations
iii. Drugs administration & dispensing
v. Radiological examinations
VI. Nursing and midwifery services
vii. Maternal Child Health/Family Planning
viii. Minor surgical procedures
x. Rehabilitation services
xi. Annual medical check-up
xii. Referral for Specialized Services
xiv. Day care services such as Manual Vacuum Aspiration (MVA), surgery and other medical services deemed fit by the clinician

NHIF Inpatient Coverage

Inpatient care may include all medical and surgical conditions which need admission and where the management will be of therapeutic value. The Inpatient cover includes the following:

❖ Hospital accommodation charges
❖ Nursing care
❖ Diagnostic, laboratory or other medically necessary facilities and services
❖ Rehabilitation services
❖ Operating theatre services
❖ Specialist consultations or visits
❖ Radiology services
❖ Drugs prescribed by treating clinician
❖ Pre-hospitalization procedures such as laboratory, x-ray or other medical diagnostic procedures and tests

NHIF OPTICAL & DENTAL COVER Coverage

The Dental Cover includes dental consultation, orthodontics, root canal, dentures, Cost of filling, X-rays and Extractions including surgical extractions together with anaesthetics fees, hospital and operating theatre cost.

Optical Care A member shall benefit in the proportion of expenses on a Fee for Service basis as per their limits for the cost of the eye glasses and eye testing.

NHIF EMERGENCY MEDICAL SERVICES

Emergency Road Ambulance
Provision of ambulance services for transportation and transfer of a sick member or dependant for treatment from a place of incident or facility where adequate care is not available to the next available NHIF accredited hospital.
Kenya Red Cross- Toll free 1199- others 0700 395395, 0738395395

Emergency Air Rescue
Emergency Air Rescue Services – KIDL Helicopters call centre
Manager 0786412324, escalation Desk 0721225423; call centre
0730702000

NHIF PRE- AUTHORIZATION & REFERRAL

NHIF Pre Authorization
The hospital will notify NHIF for authorization in cases of
❖ Day Care Surgery, Optical And Dental, Admissions, Oncology, Radiology Services Specialized
Diagnostic Or Test e.g. Endoscopy.

NHIF Referral Protocol
A scheme member shall seek treatment in the recognized health care facility. However, where the facility lacks a particular service, the facility shall refer the member to any other health provider where the service is available.

NHIF SPECIALIZED TREATMENT – ON REFERRAL

The members and declared dependants shall be covered for:
❖ Hearing aids
❖ Pressure Stockings
❖ drug and substance abuse
❖ rehabilitation services
❖ Renal dialysis
❖ trauma, diabetes
❖ Hypertension
❖ IVF
❖ MRI & CT-scan
❖ Kidney transplant
❖ Oncology (Cancer and related treatment to cancer)

NHIF ANNUAL MEDICAL CHECK – UP

The principal member and spouse are eligible for annual general medical check-up at an NHIF recognized healthcare facility for the scheme beneficiaries. Medical check-up will entail examination of the following:
i. Body mass index
ii. Full Haemogram
iii. Cholesterol
iv. Blood sugar
v. Gamma GT
vi. Urinalysis
vii. PSA (Prostate Specific Antigen for Men)
viii. Pap smear for all women
ix. Mammogram
• NB: Health Care Facilities that are unable to offer the above scope of services are advised
to refer the member to other facilities (members shall not be required to pay for these
services on referral).

NHIF OVERSEAS TREATMENT

Treatment costs arising from a condition that warrants treatment overseas when the treatment is not available in Kenya or as advised by a medical practitioner will be covered subject to preauthorization from NHIF and other relevant bodies(Director of Medical Services & Specialised Consultant)

NHIF LAST EXPENSE COVER

NHIF shall upon death of a member of the negotiated scheme, pay to the next of kin or such other
person as directed, the amount specified in the limits within two (2) days to cater for the funeral
expenses.

Requirements
The declared next of kin will be required to complete the form and forward to the respective head of human resource management with the following documents.
a. Original burial permitb. Duly completed claim form.
NB: The Original burial permit will be returned to the next of kin after payment.

NHIF Insurance Treatment EXCLUSIONS

NHIF shall not be liable for Treatments arising from non-accredited health facilities and/or un-authorized referrals
Cosmetic surgery or beauty treatment Massage (except where certified as a necessary part of treatment
following an accident or illness).

Treatment by acupuncturists and herbalists
Stays and/or maintenance or treatment received in nature cure clinics or similar establishments
Stay in private beds registered within a nursing home, convalescent and or rest homes or ‘cures’ attached to such establishments

Treatments not covered under the contract-stay overseas more than six weeks.

All other Vaccines except KEPI vaccines, Rota virus vaccine, Antrabies,Anti-Snake venon and yellow fever vaccine(NHIF to liase with MOH and County Governments in the provision of these