For the healthcare providers, NHIF proposed two contract options: comprehensive and non-comprehensive. High-end private hospitals are covered by the non-comprehensive contract, but all public hospitals as well as some mission and faith-based hospitals are covered by the comprehensive contract.
Expensive hospitals are included in non-comprehensive (group C). The NHIF pays a daily fixed rate in this category. Insurance company pays Sh4,000. Either directly or through another insurance company, the patient is responsible for paying the difference between this refund and the hospital charge. For instance, the NHIF will only reimburse Sh4,000 at a high-end private hospital where a regular room costs Sh11,500 per night, leaving the patient responsible for the remaining amount.
Some hospitals in contract B, which is mostly for mission and faith-based hospitals, fall under comprehensive coverage while others do not. The NHIF typically co-pays for some major surgical cases in addition to covering the cost of a bed and all other services. In other words, some surgical procedures are covered by the patient. Every public and governmental hospital is covered in full by NHIF under contract A. A patient enters with the card and exits without making a payment.
However, many Kenyans are curious as to why such contracting choices were made, given that many public hospitals lack adequate equipment. “We received numerous complaints regarding [NHIF’s] large payments to private hospitals. We developed the contracts after taking their feedback into consideration and standardizing the refunds across all institutions.
The turnaround has not gone unnoticed by many Kenyans for an organization with a relatively somber past and a dark, menacing shadow still hanging over it. In regards to public hospitals, Dr. Kamunyo stated, “We agreed with the hospitals on the package that they charge on every service and patients should not pay anything while they are seeking services. “In the event of an additional fee, the hospital must first obtain [NHIF’s] prior authorization before providing the treatment. Our packages did not appeal to the elite hospitals. The patient pays the bill, and that is the only arrangement we have with [them]. You are responsible for paying the hospital bills if you want to visit one.
The standardized rates across all healthcare providers is the most significant accomplishment we have made in the last year. Payments for claims are standardized. Additionally, public hospitals gain more from this. This is the reason some hospitals decided to pay their costs independently and without using the [NHIF] card. Only rebates are covered by [the NHIF card], which also applies to all medical institutions. Some hospitals believe the NHIF packages are inappropriate for them based on their business models, infrastructure, and specific facilities. For them, everything is reasonable and proper.