Table 3 NHIF Provider payment methods and rates [22]
Provider payment method | Healthcare benefit package | Reimbursement rate 1USD = 100 KES | |
|---|---|---|---|
Capitation | Outpatient services for national scheme members | KES 1200 (USD 12) per beneficiary per year for basic care facilities a(Level 3 and 4) | |
KES 1400 (USD 14) per beneficiary per year for tertiary care facilities a(Level 5 and 6) | |||
Outpatient services for civil servants (and other enhanced schemes) of lower job group (A-K or its equivalent) | KES 1500 (USD 15) Public hospitals | ||
KES 2850 (USD 28.5) Private hospitals | |||
Case-based payment | Renal dialysis (pre-dialysis, intra-dialysis and post-dialysis care) | KES 9500 (USD 95) per session twice weekly | |
Kidney transplant package- surgical costs and duration of hospitalization | KES 500000 (USD 5000) | ||
Maternity package for National scheme | KES 10000 (USD 100) Normal child birth | ||
KES 30000 (USD 300) Caesarean section | |||
Maternity package for the Free maternity program | KES 5000 (USD 50) for normal child birth or caesarean section | ||
Oncology package- treatment for cancer patients using radiotherapy or chemotherapy case management | Radiotherapy • KES 18000 (USD 180) per week | ||
Chemotherapy • Basic- KES 25000 (USD 250) per cycle • Complex- KES 150000 (USD 1500) per cycle | |||
Surgical package (covers even cancer surgeries) | Major surgeries • KES 80000 (USD 800) for level 3 and 4 facilities • KES 130000 (USD 1300) for level 5 and 6 facilities Minor surgeries • KES 30000 (USD 300) for level 3 and 4 facilities • KES 40000 (USD 400) for level 5 and 6 facilities Specialised surgeries • KES 500000 (USD 5000) | ||
Rehabilitation package (drug and substance abuse) | KES 30000 (USD 300) per year | ||
Fee-for-service | Radiology package | MRI capped at KES 15000 (USD 150) CT scan capped at KES 8000 (USD 80) | |
Dental cover (Enhanced schemes only) [16] | Capped at KES 50000 (USD 500) per annum | ||
Optical cover (Enhanced schemes only) [16] | Capped at KES 40000 (USD 400) per annum | ||
Maternity package for Enhanced schemes | Capped at KES 200000 (USD 2000) | ||
Inpatient care (medical and surgical conditions that require admission) for Enhanced scheme members of higher job groups (L and above or its equivalent) [14] | Job group or its equivalent | Annual limit | |
L | KES 1000000 (USD 10000) | ||
M | KES 1250000 (USD 12500) | ||
N | KES 1500000 (USD 15000) | ||
P | KES 1750000 (USD 17500) | ||
Q | KES 2000000 (USD 20000) | ||
R, S, T | KES 2250000 (USD 22500) | ||
Outpatient care (curative and preventive services) for Enhanced scheme members of higher job groups (L and above or its equivalent) [14] | Job group or its equivalent | Annual limit | |
L | KES 100000 (USD 1000) | ||
M | KES 150000 (USD 1500) | ||
N | KES 200000 (USD 2000) | ||
P | KES 225000 (USD 2250) | ||
Q | KES 250000 (USD 2500) | ||
R, S, T | KES 350000 (USD 3500) | ||
Per diem | Comprehensive inpatient care (Covers medical and surgical conditions that require admission) | KES 1500–4000 (USD 15–40) for public (government) health facilities and, low- cost private facilities and mission hospitals. No co-payments. | |
Non- comprehensive inpatient care (Covers medical and surgical conditions that require admission) | KES 2000–4000 (USD 20–40) for high-end private hospitals. Members pay top up deficit by self-pay or co-insurance | ||
Foreign treatment | KES 1700 (USD 17) per day of hospitalization | ||