NHIF Cover Limits For Inpatient and Outpatient (2023)

NHIF Cover Limits For Inpatient and Outpatient (2023)

NHI focuses on affordable health services for all Kenyans. Since its establishment, the segment has been quite instrumental in establishing quality health services for Kenyan residents. This guide focuses on what you should know about NHIF cover limits.

The NHIF takes care of chronic diseases, maternity, cancer, optical services, dental care, and inpatient services. Note that if your bill exceeds what NHIF covers for you, you’ll have to dig into your pocket and top up the balance.

What NHIF cover limits offer you is a good deal. You get the opportunity to choose a hospital to register with and there’s always support ready to help if anything isn’t clear.

NHIF cover limits

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6 NHIF Cover Packages Explained

The following is a brief explanation of the packaged financed by the National Health Insurance Fund to Kenyan citizens:

1. Inpatient Cover

For the inpatient cover, NHIF will cap both normal consultation and specialist consultation, bed, accident fractures, blood transfusion, nursing services, physiotherapy, medications, accompanying treatments, surgeries, and lab services.

A bed in cheap government hospitals will cost NHIF Ksh. 1,200 per day while a bed in an expensive private hospital will cost them Ksh. 4,000 per day.

2. Maternity Cover

NHIF offers cover for normal child delivery and caesarean section delivery. Note that the C-section is more expensive than normal delivery.

NHIF covers up to Ksh. 30,000 for the Caesarean section and up to Ksh. 10,000 for normal childbirth.

Deliveries can take place in a government or private hospital.

3. Chronic Disease Cover

NHIF offers cover to members who suffer from chronic illnesses such as kidney failure and diabetes.

For a kidney transplant, NHIF will contribute a maximum of Ksh. 500,000. NHIF will also cover 2 dialysis sessions a week, with each section costing Ksh. 9,500.

The maximum cover you will get from NHIF radiology services amounts to Ksh. 18,000.

4. Cancer Cover

NHIF’s cancer care plan is currently under review to optimize the cost of radiotherapy and chemotherapy so that any Kenyan who has cancer, regardless of their social status, can access medical care.

But until then, the amount payable by the scheme is limited as follows:

a) Radiotherapy

For radiotherapy, NHIF will cover up to 20 sessions for a beneficiary at a cost of Ksh. 3,600 a week.

Patients who will have their radiotherapy at Kenyatta National Hospital (KNH) will get a Ksh. 18,000 cap each week. There is also the branchytherapy cover. NHIF will pay for 2 sessions at Ksh. 40,000 for each.

b) Chemotherapy

NHIF will cover a maximum of 6 sessions for Ksh. 25,000 per session for first-line chemo in expensive private hospitals.

The chemotherapy cover can go up to Ksh. 150,000 for a maximum of 4 sessions at a private hospital if the case is so severe.

c) Oncology

Patients under NHIF who visit oncology clinics get a cover of Ksh. 25,000 to Ksh. 150,000 per session provided the sessions don’t exceed 24 in a year.

d) Diagnostics

NHIF also offers covers of up to Ksh. 69,500 to beneficiaries for advanced tests such as the Piston Emission Tomography scan. 

5. Optical Service Cover

NHIF will offer comprehensive coverage of up to Ksh. 40,000 on optical care services each year for a family.

The optical services should be by verified hospitals.

6. Dental Care Cover

nhif dental cover

NHIF offers anesthetic dental fees as well as operation costs to its beneficiaries. Additional covers include consultation, x-rays, root canals, surgical extraction, filling, and dentures.

The amount offered by the plan as a cover for dental does not exceed Ksh. 50,000 per year per family.

How Much Does NHIF Cover for Surgery

The type of surgical procedure you undergo will determine your NHIF surgical cover.

We have 4 kinds of surgical procedures covered by NHIF and they include major surgical procedures, specialized surgical procedures, intermediate surgical procedures, and minor surgical procedures.

  • Specialized Surgical Procedure: A beneficiary of the program will be covered with up to Ksh. 500,000 for a specialized surgical procedure.
  • Major Surgical Procedure: For major surgical procedures, NHIF will cover the beneficiary with up to Ksh. 130,000.
  • Intermediate Surgical Procedure: NHIF will cover from Ksh. 40,000 to Ksh. 80,000 for an intermediate surgical procedure.
  • Minor Surgical Procedures: NHIF will cover from Ksh.10,000 to Ksh. 30,000 for a minor surgical procedure.

Apart from the surgical procedure, the amount covered by NHIF for surgeries will also depend on the hospital level to which a patient was admitted.

NHIF Cover Payment for Self-employed

NHIF expects persons who are employed to pay Ksh. 500 every month. Alternatively, they can pay Ksh. 6,000, which covers them for the whole year.

A penalty is usually imposed on any NHIF member who fails to pay on time be it self-employed or employed.

The member will be required to pay twice the amount that is Ksh. 1,000 for a self-employed member.

NHIF sets the 9th of each month as the latest day to make payment.

NHIF can be paid for right from the mobile wallet. To do this: 

  • Open the M-PESA Tool Kit and select the M-PESA Menu
  • Got to Lipa na M-PESA.
  • Choose Paybill and key in 200222 as the Business Number.
  • Provide your National ID number as the Account Number.
  • Enter the Amount you wish to pay.
  • Enter your PIN, check transaction details, and then send
  • Wait for a message confirming your payment to NHIF.

Frequently Asked Questions

1. Does NHIF Cover Dental Braces?

Dental braces fall under cosmetic industries and, sadly, NHIF does not cover that.

NHIF will only cover dental health procedures such as teeth scaling, filling, x-ray, root canal treatment, tackling bad breath, extraction, and consultation.

NHIF covers up to Ksh. 50,000 yearly per family. Dental anesthetic fees are also covered.

2. What Does NHIF Cover for Outpatient?

First, outpatients under NHIF are not limited by NHIF Supa overs as long as the hospital they attend is accredited.

What the NHIF cover will offer for outpatients include consultation fees, lab tests, immunization, drug dispensation, physiotherapy services, as well as wellness and counseling

3. Does NHIF Cover Optical Services?

Yes, NHIF also offers its beneficiaries optical covers. The optical service covers the entire family. Even so, families are limited to Ksh. 40,000 per year.

4. How Much Does NHIF Cover for Inpatients?

NHIF is going to cover bedding for Ksh. 1,200 for inpatients in low-cost government hospitals. Also, they will pay Ksh. 4,000 a day for inpatients in private hospitals.

Apart from bedding, the plan will also cover consultation, lab tests, treatment, medication, surgery, nursing care and physiotherapy.

5. What does NHIF cover in Private Hospitals?

NHIF is going to offer inpatients and outpatients all medical treatments and services provided at any verified private hospital countrywide.

Some of the hospital bills covered by NHIF will include hospital beds (for inpatients), consultation (normal and specialist), medications, nursing care, operating theatre cover, referral cover, radiology services, optical care, dental health, and minor surgeries.

6. Can I Use NHIF Outpatient in any Hospital?

Unfortunately, you cannot the NHIF outpatient cover in any hospital you enter. Only the health facilities included on the patient list are acceptable.

7. Does NHIF Cover Spectacles?

Apart from using the NHIF card to pay for optical or eye surgery, beneficiaries can use it to get spectacles.

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Final Thoughts 

NHIF is a state-owned enterprise started back in 1966 as a sector under the Ministry of Health.

NHIF membership is open to all those who have attained the full age (18 years). You can insure yourself as an individual or together with your family.

At the time of this writing, NHIF has 95 offices and is present in the 47 Huduma Centers across the country to offer quick responses to customers.

Some of the health covers offered to patients by NHIF include inpatient and outpatient cover, chronic disease, maternity, dental, optical, cancer, and surgical cover.

Yu Team

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