The Ministry of Health has unveiled extensive regulations to govern the newly established Social Health Insurance system that aims to provide universal health coverage to all citizens.
The legal document, signed by Health Cabinet Secretary Nakhumicha S. Wafula, was published on November 28 and provides a blueprint for the operationalization of the Social Health Insurance Act’s three health funds.
Mandatory Registration Requirement
The regulations stipulate that all Kenyan residents must register with the Social Health Authority within 90 days to be assigned a unique Social Health Insurance Number. This includes both citizens as well as legal residents.
Registration will be done online via the Authority’s Centralized Digital Platform. Applicants will need to provide biodata, fingerprints and other biometrics. Those unable to register digitally can visit Huduma service centers.
Contribution Rates and Premiums Outlined
Salaried employees will contribute 2.75% of gross monthly wages toward health insurance, subject to a minimum of KES 300 per month. Payroll deductions apply.
For the self-employed and informal sector, mandatory premium payments have been set at 2.75% of income as assessed through proxy means testing procedures laid out in the regulations. Minimum thresholds still apply.
The government will fully subsidize contributions on behalf of indigents and vulnerable groups. Others eligible for full sponsorship include persons in lawful custody and adults over 25 without an income.
Three-Tier Benefits Structure Established
Clear distinctions have been drawn on the essential healthcare package provided under each of the Act’s three funds:
The Primary Healthcare Fund will cover mainly outpatient primary care services at Level 2 and 3 facilities like health centers and clinics.
More advanced inpatient and outpatient services across Level 4-6 hospitals fall under the Social Health Insurance Fund. These range from dialysis to MRI scans and surgery.
High-end packages have been carved out under the Emergency, Chronic and Critical Illness Fund. Cancer treatment, overseas referrals and critical care beyond Social Health Insurance caps will be paid from this pool.
Empaneled Facilities Only for Claims
To receive reimbursements, healthcare providers must undergo vetting and accreditation by the Social Health Authority. Moreover, both public and private facilities will need to sign contracts stipulating quality standards.
Emergency care has been exempted from this restriction on empaneled facilities. Ambulances and evacuation services are also covered under the emergency benefits package.
Oversight on Packages and Tariffs
An 11-member expert advisory panel headed by a local public university will review benefits packages and tariffs every 2 years and recommend changes to the Cabinet Secretary and Social Health Authority Board.
Rates paid to facilities will be guided analysis of cost of interventions, health technologies assessment and actuarial studies.
Payments to be Centralized Digitally
The regulations mandate setting up a real-time Centralized Digital Platform to streamline claims submissions, reviews, approvals and payments. This will unify the currently fragmented reimbursement processes.
Penalties for Default Detailed
For employers who fail to remit monthly payroll deductions and individuals who default on premiums, penalties have been listed in the regulations, which will be implemented by the Ministry of Health.
The new Dispute Resolution Tribunal will handle appeals and mediation in disputed cases.
With only 17 million Kenyans currently medically insured according to Ministry data, the regulations signify a major step towards universal health coverage by 2028.
