NHIF issues new healthcare rules

Contributors to the National Hospital Insurance Fund (NHIF) will be required to identify their preferred hospitals after new rates take effect in April.  This is according to the NHIF Manager In charge of Planning and Strategy, Chacha Marwa  who in a radio interview on Thursday said that the guidelines on how this would be done are to be released before May when members begin to benefit.

He added that the fund would expand the provider base for easier access and service provision. In his words, “Any inpatient case unless an emergency, will have go through a referral process, a sieving process that starts from the lowest facility to the tertiary facility so that we will be able to categorise, because that is where the issues are.” He said it was important for members to start seeking healthcare from the lowest level of service providers like health centres or outpatient clinics for sustainability of the fund. In explaining this, he noted that Kenya was one of the few countries where the health care system has broken down, resulting in people moving directly from the household to a tertiary level facility in case of illness. “Every country that has managed their health care system has it that you have to go through a filtering process. We are not going to encourage people to just walk from home and go to the highest level of care,” he said.

On the level of care, the Manager in charge added that the members will from May benefit from a comprehensive inpatient and outpatient care after the scheme implements the new rates next month. “We do not believe in limits because limits tend to induce over utilisation where there is a tendency to maximise that limit, and especially towards the end of the year when somebody finds out they still have more. So you tend to have undue utilisation and that can be risk to sustainability of the scheme,” Marwa explained. Members and their declared dependants will benefit from all services ranging from consultation, laboratory testing, specialised treatment, X-rays, CT scan and drugs among others. The only exclusion would be cosmetic surgeries.

Marwa said  that outpatient services will be run through capitation where the health care service providers are paid a certain fixed amount for each individual covered and registered with that facility. Inpatient on the other hand will be through case management or fee-for-service, according to Marwa. “We can only limit the number of days that hospitalisation can occur, which is 180 days. For the rest we cannot put a limit. But where hospitalisation goes beyond 180 days, we deal case by case,” he said. The fund is however consulting to know whether to put a cap on services like dental and optical care.

In the case where an employee has another private insurance, the NHIF will not interfere with it. Where it is possible, the fund will invoke the principle of co-insurance, so that if a person takes insurance from two different companies, in the event that you need to use the cover, then NHIF as the party whom an individual took insurance from, have to look for ways to settle that bill.

However, the needy, who are non-members will not immediately benefit from the fund. i.e there is no way the needy are going to be admitted into the scheme if somebody does not pay for them, and this somebody could be the government, whom NHIF is already in talks with, or philanthropists, so that they can join in and benefit. He explained that the fund will require an extra monthly contribution of Sh300 per family for the non-member indigents to access cover.

The fund expects to almost triple its annual revenue from the current Sh 7 billion to Sh19 billion, after the introduction of the new member contributory rates which have gone up by over 500%. Majority of the NHIF members according to Marwa earn between Sh8, 000 and Sh30, 000 per month and their contribution will range from Sh400 to Sh1, 000 per month.

Source: Capital fm.co.ke

Edited by HERAF Staff

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