The Ministry of Health on Sunday announced a temporary pause of the Social Health Authority (SHA) overseas package to allow for key policy changes to take effect.
For the next 30 days, patients seeking SHA assistance will have to wait as the ministry upgrades the system, which is designed to encourage more Kenyans to seek treatment locally.
Under the new rules, SHA will only cover overseas treatments that are not available in Kenya. Health Cabinet Secretary Aden Duale noted that several procedures frequently sought abroad, including PET scans, advanced imaging, kidney transplants, open-heart surgeries, and treatment for joint and spinal injuries, are now available in the country.
In addition, overseas hospitals must be formally contracted by SHA, hold accreditation in their home country, and be recognised in Kenya for patients to qualify for coverage. The facilities will also be required to have a Memorandum of Understanding (MoU) with a Kenyan empanelled and contracted health facility.
The cap for overseas SHA payments will remain at Ksh500,000 per year.
"The Social Health Authority (SHA) Overseas Treatment Benefit Package under the Social Health Insurance Act allows for treatment outside Kenya at a set annual rate of Ksh500,000 for services not available locally," Duale stated.
"SHA is aligning with the law, has started contracting and is implementing a new system to improve coordination among all stakeholders."
Process for Overseas Treatment Package
Pre-authorisation
The overseas hospitals will be required to request pre-authorisation before the patient travels for treatment.
Notification
The hospitals must then notify SHA on admission and discharge of the patients.
Claim
Next, the overseas hospitals must submit claims online for adjudication and payments.
Follow-up Care
Upon return, patients will be required to access follow-up care through the local facility to which they are linked.
Early this year, on January 23, the ministry announced plans to fast-track the review of the overseas benefits package following incessant complaints from Kenyans.
"The indication initially was that we are supposed to review the tariff and benefits after two years, but because of the call from Kenyans regarding their experience with SHA, that will be done much sooner," MOH Director General Patrick Amoth said.
"The Cabinet Secretary and the Principal Secretary, State Department of Medical Services, have instituted measures to be able to ensure that the benefit package tariffs advisory panel, which is envisioned in law, is in place."
More specifically, Amoth relayed that the package would be reviewed to ensure the fundamental objective of the scheme, covering everyone, was met.
