TOPIC SEVEN

NATIONAL HOSPITAL INSURANCE FUND KENYA

Objectives

By the end of this topic the learner should be able to: -

 Explain the purpose and benefit of NHIF

 Know how to register with NHIF
 Explain the procedure for making a NHIF claim
 Know NHIF Accredited Hospitals

NHIF Act

National Hospital Insurance Fund is a State Parastatal that was established in 1966 as a
department under the Ministry of Health. The original NHIF Act of Parliament that set up this
Fund in 1966 has over the years been reviewed to accommodate the changing healthcare needs
of the Kenyan population, employment and restructuring in the health sector. Currently an NHIF
Act No 9 of 1998 governs the Fund.

The transformation of NHIF from a department of the Ministry of Health to a state of corporation
was aimed at improving effectiveness and efficiency. The Fund’s core mandate is to provide
medical insurance cover to all its members and their declared dependants (spouse and children).
The NHIF membership is open to all Kenyans who have attained the age of 18 years and years
and have a monthly income of more than Ksh 1000.

NHIF has 31 fully autonomous branches across the country. Each of these branches offers all
NHIF services including payment of benefits to hospitals or members or employers. Smaller
satellite offices and service points in district hospitals also serve these branches.

NHIF New Rates – NHIF Monthly Contribution

Below are the New NHIF deductions for NHIF new rates 2015 categorized by various monthly
income brackets.

Gross Income (Kshs) Monthly Premium (Kshs)

0-5,999 150
6,000 – 7,999 300
8,000 – 11,999 400
12,000 – 14,999 500
15,000 – 19,999 600
20,000 – 24,999 750
25,000 – 29,999 850
30,000 – 34,999 900
35,000 – 39,999 950
40,000 – 44,999 1,000
45,000 – 49,999 1,100
50,000 – 59,999 1,200
60,000 – 69,999 1,300
70,000 – 79,999 1,400
80,000 – 89,999 1,500
90,000 – 99,999 1,600
100,000 and above 1,700
Self Employed (special) 500

NHIF Rates-2015

The old premiums allowed for in-patient cover only. The NHIF new rates 2015 will enable NHIF
members to have both out-patient and in-patient covers. Services that our members will enjoy
under the out-patient cover include:

1. General consultation with general practitioners

2. Prescribed laboratory tests/investigations
3. Drugs/medicines
4. Prescribed X-rays and ultra sound diagnosis
5. Treatment of Sexually Transmitted Infections
6. Treatment, dressing or diagnostic testing
7. Family planning
8. Ante-natal and post-natal care
9. Clinical counseling services
10. Health and wellness education

NHIF Registration Form

NHIF registers all eligible members from both the formal and informal sector. For those in the
formal sector, it is compulsory to be a member. For those in the informal sector and retirees,
membership is open and voluntary. To register with NHIF as a member, fill in the NHIF
Members Form. To register as an employer or organized group, fill in the NHIF Employers
Form.

Who is Eligible?

Any person…

1. Who is a *resident in Kenya

2. Has attained the age of 18 years. (No age limit after the age of 18 years)
 3. Whose total income from salaried or self-employment is more than Kshs. 1,000 per
month or Kshs. 12,000 per year.
4. Drawing an income from Kenya
5. Working under contract or casual terms of employment
6. It also includes voluntary contributors
* This includes foreign visitors permitted to work or study in Kenya

What do I need to bring?

Kenyan Residents

1. Copy of National I.D (including spouse if applicable)

2. Copy of Employer Appointement/Introduction Letter (excludes self-employed/voluntary
contributors)
3. Coloured passport photo (including spouse & dependants if applicable)
4. Original & copies of Birth Certificate(s) for dependants

Foreign Residents

1. Copies of passport, alien certificate or work permit (including spouse if applicable)

2. Coloured passport photo (including spouse & dependants if applicable)

Foreign Students

1. Copy of passport
2. Coloured passport photo

NHIF Employer Requirements

1. Certificate of Registration
2. PIN Certificate

NHIF Kenya – NHIF Registration Procedure

1. For the employed persons, the employer is required to apply for the employee’s
registration upon employment by completing Registration Form (NHIF 2) and submitting
the same to the Fund for issuance of a card.
2. Self-employed persons should complete Registration Form (NHIF 2) and submit the
same duly completed to the Fund for issuance of a card.

NB. The above categories of contributors are subject to the same terms and conditions on
benefits, premiums and penalties.
NHIF Contributions – Why do both spouses have to contribute and can they use both cards
to claim?

Under the law, all persons resident in Kenya, over 18 years and whose total income is not less
than Kshs. 1,000 in any given month are required to contribute to the Fund irrespective of
whether the spouse is a contributor or not. Whereas any card can be used to pay a claim at any
given time, both cards cannot be used to pay the same claim at the same time because NHIF
policy does not give provision for this.

An individual is eligible to be a member of NHIF once he attains the age of 18 years. However,
the individual will benefit from NHIF cover if the said individual has been declared a dependant
because:

1. Is undergoing a full time course of education at a university, college, school or any other
educational establishment. In this case the contributor is required to produce evidence
from the educational establishment as proof of dependence.
2. Having attained the age of 18 years, is either mentally or physically handicapped and is
wholly dependant on and living with the contributor.

If a person happens to change employer, the new employer should inform NHIF for updating of
records. Likewise, the old employer should inform NHIF when an employee is leaving.

NHIF deductions

The employer is responsible for making deductions and remitting to NHIF by the due date,
which is the 9th of every month.

1. A Penalty of five (5) times amount of contributions due will be levied for late payment
payable by the employer
2. All payments for contributions must be accompanied by payroll information showing
individual employee’s contributions paid.
3. NHIF will only refund contributions which have been paid in error.
4. Contributions for informal sector will be done by individual contributors.

NHIF Membership Number and Card

Urgent cards take 24 hours to be printed. Normal cards will take up to 14 days. A member can go
to the nearest NHIF office to inquire if the card has been printed once the set deadlines have
elapsed.

NHIF Mpesa Contributions

To pay via your mobile phone (enabled with Mpesa service) follow these simple steps:
1. Select the Pay Bill option
2. Enter Busines no. – Type in 200222
3. Enter a/c no – Type in contributor’s National Identity Number
4. Enter amount – Type in the amount you wish to contribute
5. Enter pin – Type in your Mpesa Pin
6. Confirm all details are correct then press OK

NHIF Kenya Claims

What are the procedures for making a NHIF claim?

There are two types of claims for NHIF namely:

Hospital Claim: A claim submitted by a hospital after allowing NHIF benefits to a contributor.
For a hospital claim attach:

1. Completed and signed admission and claim Form NHIF 8.

2. Hospital statements/invoices.
3. NHIF members’ card.
4. Certificate of contributions paid where applicable.
5. Photocopies of both sides of a contributor’s NHIF card.
6. Photocopies of both sides of a contributor’s identity card. And that of spouse if she is the
patient.
7. Cash receipts/invoices must have hospital seal.
8. Case summary

General Claim: A claim lodged directly with the Fund by a contributor after paying his bills at
the hospital. This includes foreign claims. For a general claim attach:

1. Duly completed claim form

2. Original invoices and cash receipts from the hospital (these should be stamped/sealed
depending on the type of hospital)
3. Copy of national id for the contributor
4. Copy of national id for the spouse or copy of birth certificate for a child in the event that
a dependant was hospitalized
5. Discharge summary
6. Certificate of contributions paid where applicable

NHIF Kenya – Why are claims not paid within the stipulated time?

The Fund strives to pay claims within 14 working days upon receipt from the hospitals. Members
who opt to clear the bills with the hospital may launch a general claim directly to NHIF for
reimbursement. Once a claim is submitted, it is examined by the Fund to ensure validity before
payment. A claim can however be rejected and the hospital/member informed accordingly to
incorporate either the missing documents or to address the abnormalities identified. This process
may delay payments. A claim that is submitted or lodged with the Fund 90 days after the date of
discharge.

NHIF Kenya – Who should sign the claims presented to the Fund in the absence of the
Contributor?

Only the contributor is allowed to sign the claim form, but in cases where the contributor is
unavailable, either because of death or is incapacitated, the spouse or the legal representative of
the contributor may sign the claim form. However, in such circumstances a letter explaining the
reasons thereof should be attached. The card can pay up to 1700 per day when treatment is
sought outside the country

In case of death the claim can be lodged by the next of kin who will be required to attach the
death certificate. However, payment will be made to the Public Trustee or Legal Representative
(administrator of the estate).

All interested hospitals that meet the accreditation standards as set by NHIF will be contracted to
provide services to our members. NHIF does not discriminate against any illness.

The validity of the NHIF card ceases with the death of the contributor, subject to it having been
paid up to the date of death. However, if the deceased had paid for the entire period of the
financial year, the contributors spouse may apply for membership and will be eligible for cover
for the period already paid for. At the end of such period, the spouse will continue to contribute
as the principal member.

The employer is liable to pay penalties on late contributions .In the case of self-employed
persons the contributor himself/herself is liable.

Obligation of a self-employed person under the Act

A self-employed person earning an income of Kshs. 1,000 or above per month or 12,000 per year
is required by law to pay a monthly contribution of Kshs. 160 by the 9th of every month. Failure
to do so will attract a penalty of 5 times the contribution due. However, due to earning
fluctuations, self-employed persons are allowed to make upfront payments in quarterly, half
yearly and on annual basis.

NHIF Accredited Hospitals

This comprehensive in-patient health cover has been introduced for NHIF contributors and their
dependants. The actualization of this package is a culmination of continued reforms at NHIF.
Such reforms include efficiency, arising from decentralization of NHIF services and continued
partnership with health providers on enhanced quality services to all members. To enhance these
benefits, NHIF has contracted hospitals under three Categories; A, B & C, to provide this in-
patient medical cover and partial cover for surgical cases in some of these hospitals. Our
members are at liberty to attend hospitals under any category.
NHIF Accredited Hospitals – Category A (government hospitals)

Under Category A (government hospitals), members would be able to enjoy full and
comprehensive cover for maternity and medical diseases including surgery. In short, they will
not need to pay for anything on admission provided they are fully paid up members of NHIF.

NHIF Accredited Hospitals – Category B (private and mission)

Members admitted under contract Category B (private and mission) hospitals will enjoy full and
comprehensive cover but where surgery is required, the contributor may be required to co-pay.

NHIF Accredited Hospitals – Category C (private)

Those visiting facilities contracted under Category C (private) will continue with the current
system where NHIF pays specified daily benefits under the current arrangements. NHIF will
continue to negotiate with other health providers not appearing in the list below to determine
which category of contract they will sign. Members will be informed of additional hospitals as
and when they sign the contracts.

For a comprehensive list of Hospitals, Number of Beds and Contracts covered by NHIF visit the
NHIF Website here: http://www.nhif.or.ke/ Under Hospitals.

BENEFITS OF NHIF

 Upon admission in hospital an NHIF member is accorded services and the hospital makes
a claim to the Fund for reimbursement
 An in-patient cover for the contributor, declared spouse and children
 Provides comprehensive medical cover in majority of over 400 accredited Government
facilities, Mission health providers and some private health providers across the country
 Provides in-patient services in private and high cost hospitals on a co-payment basis
 Comprehensive maternity and CS (Caesarian) package in government hospitals, majority
of mission and some private hospitals
 Dialysis at Ksh 2,500 per session at the following medical facilities:-

- Kenyatta National Hospital, Nairobi

- Moi Teaching & Referral Hospital, Eldoret
- Provincial General Hospital Kisumu
- Rift Valley Provincial General Hospital, Nakuru
- Coast General Hospital, Mombasa
- Siloam Hospital, Kericho
- Mediheal Hospital & Fertility Centre
- Muranga District Hospital, Muranga
- Thika Level 5 Hospital, Thika
- P.C.E.A Hospital, Kikuyu
- Consolata Hospital, Nyeri
 - Tawfiq Hospital, Malindi
- Africare Limited
- Kakamega Country General Hospital

 Family planning' Vasectomy and Tubal Ligation

 NHIF does not exclude any disease.

Sponsored Programmes

NHIF seeks to establish partnership with individuals and/organizations to finance health

insurance for indigents including orphans & vulnerable children, poor older persons, persons
with disabilities and destitute families. The indigents shall be identified by NHIF or the
sponsors.

Enrolled indigents and their dependants shall have access to the current benefit package of
inpatient cover in any of the health providers accredited to NHIF countrywid

Accrediting & Contracting Hospitals

 The Fund strives to accredit as many hospitals as possible so as to ensure all members
access NHIF benefits whenever they are across the country.
 NHIF has an objective accreditation criteria and guidelines that aim to encourage
hospitals towards quality improvement.
 Accredited organizations are those recognized by the Fund and allowed to offer services
to NHIF members and claim reimbursements thereof.
 Accreditation of a health provider takes into account the services, personnel,
infrastructure and equipment among other issues that the institutions have. The level of
rebate therefore corresponds to the grade after scoring the various aspects.
 The Fund, further contracts the health facilities to ensure they provide services
comprehensively. This means that NHIF members walk in and walk out of the facilities
fully treated at the cost of NHIF without making additional payments.
 The contracts spell out the obligations of the health provider and NHIF