NHIF Cover Limits Revealed: Here is the Amount NHIF Pays

The National Hospital Insurance Fund (NHIF) Kenya pays different amounts for its insured members. Although NHIF covers both inpatient and outpatient medical services, the limits of the amount paid for services vary. For this reason, it is worth noting the NHIF cover limits as this will enable you to know the amount to be remitted by NHIF in case of a medical condition. If you are covered by NHIF, you can use these limits to plan yourself financially for a certain treatment. You will be aware of your out-of-pocket payment and this will eliminate confusion when you get to the health facility. Here are the NHIF cover limits for different medical services.

The following are the available NHIF cover limits:

  • Inpatient cover
  • Outpatient cover
  • Maternity cover and reproductive health
  • Cance cover (Oncology package)
  • Chronic disease cover
  • Imaging services cover
  • Surgeries cover
  • Dental care cover

Inpatient NHIF Cover Limits

NHIF cover limits
Inpatient Services

Inpatient care is one that requires you to stay in the hospital. Therefore, you will incur some charges as a result of services rendered to you as you stay in the hospital. These may include food and bed. The NHIF inpatient cover includes:

  • Nursing care
  • Theatre operation services
  • Radiology services
  • Pre-hospitalization procedures like laboratory, tests, and procedures.
  • Hospital accommodation charges
  • Diagnostic, laboratory, and other medical necessities.
  • rehabilitation services
  • Specialist consulations or visits

The NHIF cover limits for inpatient services are as follows:

  • High-cost private hospitals: Ksh. 4,000 per day maximum coverage
  • Low-cost government hospitals: At least Ksh. 1,200 per day.
  • Limits on other medical services will depend on the category of your hospital

Find out: Easiest Way to Check Your NHIF Status Online

Outpatient NHIF Cover Limits

Outpatient medical services are the ones that do not require you to stay in the hospital. You will be visiting the hospital on the dates specified by your doctor. NHIF covers both preventative and curative outpatient services as follows:

  • Consultation
  • Laboratory services
  • Drugs administration and dispensing
  • Radiological examinations
  • Rehabilitation services
  • Annual medical check-up
  • Referral for specialized services
  • Maternal child health/Family planning
  • Minor surgical procedures
  • Day care services like Manual Vacuum Aspiration (MVA) and surgery.

In normal situations, there are no NHIF super cover limits for outpatient services provided you attend a registered hospital.

NHIF Cover Limits for Civil Servants

For civil servants in Kenya, the NHIF cover may be limited or unlimited. The determining factor is your job group. The table below will help you determine if your NHIF cover is limited or not.

Job GroupInpatient (Kshs)Outpatient (Kshs)
NHIF Cover Limits for Civil Servants

Maternity Services NHIF Cover Limits

Maternity services (Linda Mama) ensures pregnant women and infants have access to quality and affordable services. NHIF covers both normal and C-section delivery in public and a majority of private hospitals. Prenatal care services are also covered. Other services covered by NHIF include:

  • Prenatal care services
  • All Ante Natal services
  • All Post Natal Services

The Linda Mama program is meant to ensure that Kenya achieves Universal Health Care (UHC).

You should note that in terms of reproductive health cover, NHIF only pays for family planning services. However, fertility treatments are excluded.

The limits for maternity services include:

  • Normal child delivery: Up to Ksh. 10,000
  • Caesarean section delivery: Up to Ksh. 30,000

NHIF Cover Limits for Chronic Diseases and Kidney Treatment

NHIF also covers different diseases like kidney failure, hypertension, and diabetes. The following are the maximum cover limits for these services:

  1. Kidney transplants: Maximum is Ksh. 500,000
  2. Radiology services: Maximum coverage of Ksh. 18,000
  3. Monthly clinic chek-up: Maximum Ksh. 5,000
  4. Kidney renal dialysis: Maximum of Ksh. 9,500 for each session twice a week

NHIF Cover Limits for Imaging Services and Radiology

Most hospitals categorize basic ultrasound and X-rays under outpatient and inpatient services. On the other hand, MRI and CT scans are handled in contracted facilities.

Although these services are paid under the inter-hospital referral system, you may need to obtain NHIF pre-authorization to qualify. The limits for these services are:

  • CT Scans: Up to Ksh. 8,000
  • Ultra Sound: Up to Ksh. 3,000
  • MRI Scan: Up to Ksh. 15,000

NHIF Cancer Cover Limits (Oncology)

NHIF has been enhanced to cater for different cancer treatments in Kenya. This was initiated after the death of many Kenyans to cancer. At the moment, many Kenyans insured by NHIF are able to access different cancer treatments in both government and private hospitals.

The amount paid by NHIF towards cancer treatment is limited as follows:

1. Oncology Clinics

If you are a member of NHIF prescribed for an oncology treatment, your benefits will range from Ksh. 25,000 to Ksh. 150,000 per cycle. However, NHIF will not cover more than 24 sessions per year.

2. Radiotherapy

NHIF caters for 20 radiotherapy sessions under the Supa Cover category. The maximum amount paid for each of these sessions is Ksh. 3,600 or Ksh. 18,000 in government hospitals like Kenyatta National Hospital (KNH) and Moi Teaching and Referral Hospital (MTR) in Eldoret.

As expected, these limits are higher in private hospitals like Aga Khan. For example, the limit for first-line chemotherapy in such hospitals is Ksh. 25,000 per session for a maximum of six sessions.

3. Diagnostic Tests

Some advanced cancer tests like Piston Emission Tomography Scan are covered by NHIF. For this test, NHIF pays a maximum of Ksh. 69,500 at the Aga Khan Hospital.

NHIF Cover Limits for Surgeries

NHIF cover limits
Surgical Treatment

People need surgeries for different reasons. The good news for you as an NHIF member is that the scheme covers major, minor, and specialized surgeries at Ksh. 500,000 on average per person. However, this depends on the level of the hospital and the procedure called for. Therefore, the amount released to cover your surgery will highly depend on what your doctor states as the procedure to be undertaken.

The limits paid for surgeries by NHIF are as follows:

  • Intermediate Surgical Procedures: Ksh. 40,000-Ksh. 80,000
  • Minor Surgical Procedures: Ksh. 10,000-Ksh. 30,000
  • Specialized Surgical Procedures: A maximum of Ksh. 500,000.
  • Major Surgical Procedures: Limit is capped at Ksh. 130,000

NHIF Cover Limits for Dental Services

NHIF covers the following services in terms of dental care:

  1. The cost of teeth filling
  2. Extractions including the surgical procedure
  3. orthodontics
  4. Teeth dentures
  5. Dental consultation
  6. Dental X-rays
  7. Root canal
  8. Dental anaesthetics fees
  9. Operating theatre costs

The limits for dental services are based on the dental care being undertaken. However, the limit will not exceed Ksh. 50,000 per family per year.

NHIF Cover Limits for Optical Services

In this category, the government decided to make all NHIF members equal. The limit here is Ksh. 40,000 per family annually. This is irrespective of your job group.

NHIF Frequently Asked Questions (FAQs)

  1. Does NHIF cover for ultrasound?

Ultrasound services are not covered by NHIF. It’s unfortunate that if you need these services, you will be forced to pay directly from your pocket.

2. Does NHIF cover gynecologist?

Yes. NHIF covers gynecologist and other maternity services like normal and C-section delivery.

3. Does NHIF cover eyeglasses?

Yes. NHIF members are now able to access eye treatment and optical glasses after the parliament voted for this bill to become law. However, the services can only be received in accredited hospitals like the Sabatia Eye Hospital.

Final Thoughts

NHIF is meant to ensure affordable healthcare for Kenyans. Your salary bracket will determine how much you will contribute towards your medical insurance. For instance, those earning between Ksh. 0-Ksh. 5,999 contribute only Ksh. 150 to NHIF. Therefore, NHIF considers people from different social classes in society.