National Hospital Insurance Fund is a State Parastatal that was established in 1966 as a department under the Ministry of Health. The original Act of Parliament that set up this Fund in 1966 has over the years been reviewed to accommodate the changing healthcare needs of the Kenyan population, employment and restructuring in the health sector. Currently an NHIF Act No 9 of 1998 governs the Fund.

Who is eligible to apply for membership and what is the requirements/procedure?

Any person...

• Who is a resident in Kenya
• Has attained the age of 18 years. (No age limit after the age of 18 years)
• Whose total income from salaried or self-employment is more than Kshs. 1,000 per month or Kshs. 12,000 per year.
• Drawing an income from Kenya
• Working under contract or casual terms of employment 
• It also includes voluntary contributors.

The procedure for registering a new member is:

• For the employed persons, the employer is required to apply for the employee's registration upon employment by completing Registration Form (NHIF 2) and submitting the same to the Fund for issuance of a card.
• Self-employed persons should complete Registration Form (NHIF 2) and submit the same duly completed to the Fund for issuance of a card.

NB. The above categories of contributors are subject to the same terms and conditions on benefits, premiums and penalties.

Why do contributors need to present original documents? (National I.D/passport, alien certificate birth certificate/notification, marriage certificates)

For verification of the information provided to NHIF.

Why do both spouses have to contribute and can they use both cards to claim?

Under the law, all persons resident in Kenya, over 18 years and whose total income is not less than Kshs. 1,000 in any given month are required to contribute to the Fund irrespective of whether the spouse is a contributor or not. Whereas any card can be used to pay a claim at any given time, both cards cannot be used to pay the same claim at the same time because NHIF policy does not give provision for this.

Is there an age limit for registration?

NHIF has a lower age limit for registration of 18 years but it does not have an upper age limit.

Does NHIF accept traditional marriages?

Yes, however you are required to produce a sworn affidavit from the Magistrate.

Can we cover children above 18 years waiting to join college?

An individual is eligible to be a member of NHIF once he attains the age of 18 years. However, the individual will benefit from NHIF cover if the said individual has been declared a dependant because:

• Is undergoing a full time course of education at a university, college, school or any other educational establishment. In this case the contributor is required to produce evidence from the educational establishment as proof of dependence.
• Having attained the age of 18 years, is either mentally or physically handicapped and is wholly dependant on and living with the contributor.

What are the procedures for covering children in children's homes?

A policy is being designed which once in place, will address this issue.

If one has been a contributor for sometime and has not received an NHIF card, does it mean that such person is not properly registered?

Yes. One is only a contributor but not a member if they have not submitted a duly completed NHIF 2 form to NHIF for processing and issuance of an NHIF card. It is the responsibility of an employer to ensure that a contributing member is registered and issued with a membership card.

What happens when one changes employment?

The new employer should inform NHIF for updating of records. Likewise, the old employer should inform NHIF when an employee is leaving.

What should be done with the NHIF card when a contributor retires, is terminated, emigrates or dies?

The card is the property of the Fund and should be returned immediately for record and custody. Other than a contributor who dies, the rest can re-apply if they wish to continue with membership.

Who is responsible for making NHIF deductions?

The employer is responsible for making deductions and remitting to NHIF by the due date, which is the 9th of every month.

• A Penalty of five (5) times amount of contributions due will be levied for late payment payable by the employer
• All payments for contributions must be accompanied by payroll information showing individual employee's contributions paid.
• NHIF will only refund contributions which have been paid in error.
• Contributions for informal sector will be done by individual contributors.

What is the procedure for asking for increase of NHIF rebates?

The increase of rebates is granted on the basis of improvement of facilities and nursing care provided in the hospital. If such improvements have been made then the proprietor can apply to the Fund for consideration.

Can rebates be decreased?

Yes. If the standards laid down by the Board of Management for a given hospital deteriorate then the rebates can either be decreased or the hospital degazetted.1

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2. Company Registration Questions

What are the requirements/procedure for registering a new company?

The company will be required to fill form NHIF 33 and attach certificate of registration and the PIN certificate. A compliance check will then be carried out by NHIF.

What is the procedure for change of company name?

A letter advising the Fund of the said changes will be required. You will also be required to fill an amendment form.

Can employers do up front payments before being issued with a code?

No, this will not be possible because the code is the account number that enables payments to be made.

How long does it take to inspect a new company?

There is no set time frame of how long this should take, but ideally it shouldn’t take more than two days because NHIF has assigned inspectors to cover specific regions.

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3. Registration of Foreigners Questions

What are the requirements of registering foreigners?

The resident is required to apply for the registration by completing a Registration Form (NHIF 2) and submitting the same to the Fund for issuance of a card. He will also be required to present original and attach copies of passport, alien certificate or a work permit. If the said foreigner has dependants, he will be required to attach documents such as birth certificates, spouse’s passport or alien certificate and their current passport size photos.

What are the requirements for a foreign student with a student visa who wishes to register with NHIF?

Since NHIF also covers residents, the student will be covered under the self employed category. The student should complete a Registration Form (NHIF 2), present original and attach copies of passport, passport size photo and the required amount and submit the same duly completed to the Fund for issuance of a card.

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4. Membership Card Questions

How long does it take to print a card?

Urgent cards take 24 hours to be printed. Normal cards will take up to 14 days. A member can go to the nearest NHIF office to inquire if the card has been printed once the set deadlines have elapsed.

What does one have to do to obtain the card for the second or of the wives? Are children of other spouse(s) beneficiaries?

The contributor is at liberty to apply for a card for his second or other wives not named in his first card. The children of a contributor irrespective of their mother or father are eligible to benefit so long as they are dependant on the contributor.

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5. Amendments/Refunds Questions

What is the procedure for making amendments on the NHIF membership card?

A member wishing to make amendments for purposes of updating records should complete an amendment form indicating the desired change.

Requirements:

Why can't members who retire from employment be refunded their contributions with interest?

The Fund is not a Social Security Scheme or Provident Fund where members who retire from employment are paid their savings plus interest. The Fund is a social health insurance scheme which pays only when the contingency assured against occur i.e. contributor or a member of his family is hospitalized. Retirees are encouraged to continue with membership to NHIF as voluntary members.

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6. M-Pesa Questions

Can M-pesa service be used by companies?

No. At the moment the service is only available to self-employed members.

What are the procedures of paying via M-pesa?

To pay via your mobile phone (enabled with Mpesa service) follow these simple steps:

You will receive a confirmation SMS from Mpesa immediately.

Transaction charges are as follows:

NB: This option is only available to voluntary contributors & the self employed.

Ensure that you pay your bill before the 9th of every month to avoid penalties. In case of any queries call NHIF customer care at toll free number 0800 22135649 or Safaricom customer care 234 for free.

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7. Claims Payment Questions

What are the procedures for making a claim?

There are two types of claims for NHIF namely:

Hospital Claim: A claim submitted by a hospital after allowing NHIF benefits to a contributor. For a hospital claim attach:

• Completed and signed admission and claim Form NHIF 8.
• Hospital statements/invoices.
• NHIF members’ card.
• Certificate of contributions paid where applicable.
• Photocopies of both sides of a contributor’s NHIF card.
• Photocopies of both sides of a contributor’s identity card. And that of spouse if she is the patient.
• Cash receipts/invoices must have hospital seal.
• Case summary

General Claim: A claim lodged directly with the Fund by a contributor after paying his bills at the hospital. This includes foreign claims. For a general claim attach:

• Duly completed claim form
• Original invoices and cash receipts from the hospital (these should be stamped/sealed depending on the type of hospital)
• Copy of national id for the contributor
• Copy of national id for the spouse or copy of birth certificate for a child in the event that a dependant was hospitalized
• Discharge summary
• Certificate of contributions paid where applicable

Why are claims not paid within the stipulated time?

The Fund strives to pay claims within 14 working days upon receipt from the hospitals. Members who opt to clear the bills with the hospital may launch a general claim directly to NHIF for reimbursement. Once a claim is submitted, it is examined by the Fund to ensure validity before payment. A claim can however be rejected and the hospital/member informed accordingly to incorporate either the missing documents or to address the abnormalities identified. This process may delay payments.

How and when does a claim become a late claim?

A claim that is submitted or lodged with the Fund 90 days after the date of discharge.

Who should sign the claims presented to the Fund in the absence of the Contributor?

Only the contributor is allowed to sign the claim form, but in cases where the contributor is unavailable, either because of death or is incapacitated, the spouse or the legal representative of the contributor may sign the claim form. However, in such circumstances a letter explaining the reasons thereof should be attached.

Does the Fund cover treatment received outside the country and to what extent?

Yes the Fund covers treatment obtained outside the country. The rate currently is Kshs. 1,700 per day.

In case where the patient is a contributor and he happens to die, who is entitled to lodge a claim on his behalf and how?

The claim can be lodged by the next of kin who will be required to attach the death certificate. However, payment will be made to the Public Trustee or Legal Representative (administrator of the estate).

If a credit card is used for settlement of medical bill what would be the procedure for claiming benefits?

The contributor will be required to complete all necessary claim documents and attach proof that the hospital has been paid.

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8. Benefits Questions

Are there plans to include St. Mary’s hospital in the list of accredited hospitals?

Yes, the Fund is pursuing this issue. Talks with St. Mary’s management have already been initiated.

Will I visit the hospital of my choice?

Yes, every member shall have an opportunity to visit a facility of their choice as long as it has been accredited.

Will NHIF improve their services?

The organization has an elaborate system of performance management that ensures we continuously improve our services.

Which hospitals will cover out patient?

All interested hospitals that meet the accreditation standards as set by NHIF will be contracted to provide services to our members.

Will NHIF cover chronic illnesses?

NHIF does not discriminate against any illness.

Will there be enough drugs in hospitals?

The contract that NHIF enters into with the accredited facilities ensures that the facilities continuously have enough drugs supply. There is also a Quality Assurance program to be undertaken by the contracted facilities and this is regularly monitored by NHIF.

Does NHIF refund a contributor who never utilizes his/her contributions?

No. The principle of insurance calls for "pooling of Funds" from many insured members in order to pay for relatively uncommon but severely devastating losses which can occur to them. The protection is offered through a premium which is non refundable.

Can the NHIF card continue to be used by the beneficiaries after the death of the contributor?

The validity of the NHIF card ceases with the death of the contributor, subject to it having been paid up to the date of death. However, if the deceased had paid for the entire period of the financial year, the contributors spouse may apply for membership and will be eligible for cover for the period already paid for. At the end of such period, the spouse will continue to contribute as the principal member.

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9. Premium Rates Questions

Why the new premiums?

The old premiums allowed for in-patient cover only. The new rates will enable NHIF members to have both out-patient and in-patient covers. Services that our members will enjoy under the out-patient cover include:

• General consultation with general practitioners
• Prescribed laboratory tests/investigations
• Drugs/medicines
• Prescribed X-rays and ultra sound diagnosis
• Treatment of Sexually Transmitted Infections
• Treatment, dressing or diagnostic testing
• Family planning
• Ante-natal and post-natal care
• Clinical counseling services
• Health and wellness education

When are the new rates taking effect?

Ideally the rates took effect in July 2010 when they were gazetted. But due to a court case, implementation has been delayed until the court makes a ruling.

Why should one have two insurance covers e.g NHIF and AAR?

There are products tailored for public good and those that are meant to be enjoyed by a few people. NHIF provides products that are for the public good. Besides, it is the government’s obligation to provide healthcare to its people and it is doing it through NHIF. NHIF does not discriminate on any illness (whether pre-existing or otherwise) and age group unlike the other insurance companies. Private cover is meant to cover the few who will afford.

Did NHIF consult stakeholders?

Yes, extensive social dialogue took place between NHIF and all stakeholders who are also represented in the Board.

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10. Compliance and Penalties Questions

Who is liable to pay penalty for late contributions?

The employer is liable to pay penalties on late contributions .In the case of self employed persons, the contributor himself/herself is liable.

Is a contributor required to pay contributions for the period where no income has been earned?

No. However, contributions for this period must be updated where one wishes to claim NHIF benefits.

Is an employee expected to pay arrears of contributions where an employer has failed to remit the contributions to the Fund?

No. An employee is not expected to pay arrears of contributions and penalties where the employer has failed to do so. The law has clearly placed responsibility of deducting and remitting contributions to the Fund on the employer.

What is the obligation of a self-employed person under the Act?

A self-employed person earning an income of Kshs. 1,000 or above per month or 12,000 per year is required by law to pay a monthly contribution of Kshs. 160 by the 9th of every month. Failure to do so will attract a penalty of 5 times the contribution due. However, due to earning fluctuations, self employed persons are allowed to make upfront payments in quarterly, half yearly and on annual basis.

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