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NHIF Referral Protocol for Overseas Treatment
A plan participant will seek care at the medical centre of their choice. However, if the chosen facility does not offer a specific service, the facility must direct the member to another healthcare provider who does is accessible. The member’s chosen healthcare facility is responsible for covering the cost of such referrals. Dental and optical care, which are paid on a fee-for-service basis, shall be excluded.
In cases of day care surgery and when a member is not at their capitated facility, the hospital will notify NHIF for authorization. The Branch Manager, Deputy Branch Manager, or Head of Benefits must grant the authorization.
For complex circumstances, a Letter of Undertaking will be needed. Before going to the closest NHIF Branch office to receive a letter of undertaking, the member must first visit his outpatient facility for a referral letter.
NHIF Overseas Treatment
Beneficiaries’ medical expenses for conditions requiring care not provided in Kenya will be covered with NHIF preauthorization. The NHIF will cover the cost of the patient’s treatment, as well as the cost of travel for members or dependents, as well as the cost of travel and lodging for one companion.
On the advice of the treating physician, medical professionals accompanying a patient will be compensated for a round-trip ticket and up to two days of lodging.
When an organ transplant occurs, the NHIF will additionally cover the donor’s medical expenses and travel expenses.
As long as the major member is temporarily out of the nation on official business and the duration of any one visit does not exceed six weeks, the NHIF will pay claims for emergency medical care.
NHIF Requirements for Overseas Treatment
Letter of recommendation from the hospital or an expert consultant.
A letter supporting the referral to the Director of Medical Services from the line ministry or department.
Letter of approval from the medical services director.
Pro-forma invoice from the facility that was mentioned.
NB: Members may receive assistance from an NHIF-approved agency in locating suitable accommodations and booking travel. Get in touch with the nearby NHIF Office for additional details.
Comprehensive Medical Insurance Scheme for Civil Servants Benefits Limits of liability in Kenya Shillings
| Civil Service Grade (CSG) (Job Group – JG) | In Patient | Out Patient | Dental / Maternity | Optical | Charged within Inpatients limit |
| CSG 17-13 (A-G) | 700,000 | 70,000 | 50,000 | ||
| CSG 12 (H) | 700,000 | 70,000 | 50,000 | 40,000 | 100,000 |
| CSG 11 (3) | 700,000 | 70,000 | 50,000 | 40,000 | 150,000 |
| CSG 10 (K) | 700,000 | 70,000 | 50,000 | 40,000 | 150,000 |
| CSG 9 | (L) | 1,000,000 | 100,000 | 50,000 | 40,000 |
| CSG 8 | (M-N) | 1,500,000 | 200,000 | 50,000 | 40,000 |
| CSG 7 | (P) | 1,750,000 | 225,000 | 50,000 | 40,000 |
| CSG 6-4 (Q, R, S, T) | 2,500,000 | 350,000 | 50,000 | 40,000 | 200,000 |
