, NAIROBI, Kenya, Mar 29 – Contributors to the National Hospital Insurance Fund (NHIF) will be required to identify their preferred hospitals after new rates take effect in April.
NHIF Manager In charge of Planning and Strategy, Chacha Marwa said on Thursday that the guidelines on how this would be done are to be released before May when members begin to benefit.
He told Capital FM News in an interview that the fund would expand the provider base for easier access and service provision.
“Any inpatient case unless it is an emergency, will have to have gone through a referral process, a sieving process that starts from the lowest facility to the tertiary facility so we will be able to categorise because that is where the issues are,” Marwa said.
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.
“There is no country apart from Kenya and other countries where the health care system has broken down where you have people moving from home to a tertiary level (referral) facility,” he noted.
“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.
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.
“NHIF is always a family cover so what is entitled to the principal member accrues to the dependants,” he stated.
On Wednesday, the High Court ruled in favour of the national health insurer in a case where the Central Organisation of Trade Unions (COTU) had challenged implementation of the gazetted rates.
(<a href=”http://www.capitalfm.co.ke/news/2012/03/court-nods-higher-nhif-charges/”>See related story)
Marwa said 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 NHIF 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 fund will not interfere with it.
“Where it is possible, we will invoke the principle of co-insurance so if you take insurance from two different companies then in the event that you need to use the cover, then we, those whom you took insurance from, have to look for ways to settle that bill,” Marwa stated.
However, the indigents who are non-members will not immediately benefit from the fund.
“There is no way they are going to be admitted into the scheme if somebody does not pay for them and this somebody could be the government who we are already in talks with, or philanthropists so that they can join in and benefit,” he said.
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 seven billion shillings to Sh19 billion after the introduction of the new member contributory rates which have gone up by over 500 percent.
Majority of its members, Marwa says, earn between Sh8,000 and Sh30,000 per month whose contribution will range from Sh400 to Sh1,000 per month.