Concerns have arisen about the upcoming social health medical insurance program in Kenya, particularly regarding the perceived limitations of its benefits compared to private medical insurance schemes. For example, an employee earning a monthly take-home pay of Ksh.100,000 will contribute 2.75% to the medical scheme, equating to Ksh.2,750 per month, or Ksh.33,000 annually.
In terms of maternity care, the reimbursement under the new model is Ksh.10,000 for a normal delivery and Ksh.30,000 for a caesarean section. In contrast, private insurers offering similar salary contribution scales provide Ksh.20,000 more for a normal delivery and an additional Ksh.20,000 for a caesarean section.
For inpatient services, the new scheme offers Ksh.2,240 per day for a maximum of 180 days per household annually. In comparison, private insurers generally cover up to half a million shillings per year, which far exceeds the current model’s offerings.
The limits for dental and optical care are also significantly lower. The new program allocates Ksh.2,000 per household per year for dental care, while other providers typically offer Ksh.10,000. For optical care, beneficiaries receive Ksh.950 for eyeglasses and an annual limit of Ksh.1,000, whereas other insurers provide between Ksh.7,000 and Ksh.10,000 for similar services.
In addition, there are inconsistencies in coverage for emergency, chronic, and critical illnesses. Emergency services are covered for a maximum of 24 hours, while the new scheme’s package begins after 24 hours. Critical illnesses are covered for a maximum of 180 days under the new model.
Certain treatments and services are excluded from the plan, including assisted fertility treatments like IVF, vaccines, cosmetic procedures, weight management treatment drugs, nutritional supplements, coverage for epidemics and pandemics, professional fees above prescribed rates, and costs for diagnostic equipment.
