MEDICAL HEALTHCARE COVER FOR TEACHERS AND THEIR DEPENDANTS (INCLUDING LAST EXPENSE)
As an initiative toward the implementation of the National Policy on Universal Health Care for the citizens, the Teachers Service Commission has contracted Minet Kenya Insurance Brokers Limited, (leading other service providers) to offer a medical cover for all teachers in their employment, together with their dependants with effect from 1 st December 2022.
MEMBERSHIP ELIGIBILITY
Eligibility Criteria
- All teachers in active service aged 18 years up to 65 years
- One (1 ) legal spouse of the teacher
- Four (4) dependant children (biological/legally adopted) are eligible for cover from birth until the age of eighteen (18) years or to the age of twenty-five (25) years if residing with their parents and enrolled in a recognized post-secondary institution.
No maximum age limit shall apply to child dependants with proven disability status.
The maximum family size is six (6), comprising the principal member plus five (5) dependants.
CO-PAY
There shall be a co-pay chargeable of Kenya shillings one hundred (Kshs. 100) per outpatient visit per individual for dental, optical and specialized doctor consultation services.
The co-pay shall not be charged on repeat visits services within 14 days from date of previous visit and when picking medication for chronic conditions which does not require consultation with the doctor after 90 days from last visit.
SCHEME BENEFITS STRUCTURE
The Scheme benefits are graduated according to grading as outlined below: –
Unlimited benefits for both Inpatient and Outpatient for Job Group B5 – C3 shall apply to Government Hospitals, Faith Based Hospitals (Missionary Hospitals), and private hospitals owned by the Capitation Provider. Teachers in this category who wish to seek medical services from alternative empanelled hospitals shall be free to do so under the above limits.
Starting this month, the 1.2 million-odd beneficiaries of the Sh14 billion cover will get an inpatient cover of between Sh1 million and Sh3 million.
Optical and dental cover will now be a flat rate of sh60,000 and Sh45,000 respectively, for all teachers and their dependents. Previously, these covers were pegged at Sh45,000 and Sh35,000 respectively.
Maternity cover will now range from Sh120,000 to Sh300,000. Previously, this cover ranged between Sh100,000 and Sh375,000.
SCOPE OF COVER
The Medical cover includes Inpatient, Outpatient, Dental, Optical, Maternity, funeral (including mortuary fees, hearse, coffin, wreath, and transport for immediate family of maximum 10 people), air evacuation allocation, evacuation allocation-air (fix wing and helicopter) international travel and referral allocations.
Inpatient Benefits
This is treatment which will require admission in and stay in a hospital or day care surgery/procedure. The benefits (paid net of NHIF rebates) under this cover include but are not limited to: –
Doctor’s (Physician, Surgeon Anesthetist) Fee.
 ICU/HDU/CriticaI care and theatre Charges
- Drugs/Medicines, dressings and internal surgical appliance
- Pathology/Laboratory
- X-ray, Ultrasound, ECG and Computerized Tomography, MRI Scans
- Radiotherapy and Chemotherapy
- In-Patient Physiotherapy, Hydrotherapy
- Occupational therapy
- Hospital accommodation for accompanying parent and /or guardian for hospitalized children below seven (7) years
- Medical education and wellness program for members with pre-existing and chronic conditions
- Medical Emergency Road evacuation services leading to admission
- Congenital defects/genetic disorders
- Post- Hospitalization benefit of up to two (2) weeks for other sicknesses and six (6) weeks for accident cases after discharge.
- Day care Surgery for minor surgical treatment that may not require admission
- In-vitro Fertilization (IVF)
- Renal dialysis
- Cancer Treatment and related procedures and tests.
Outpatient Benefits
This is treatment that does not require admission or stay in a hospital or day care. The outpatient benefits include but not limited to: –
- Routine outpatient consultations.
- Prescribed Diagnostic Laboratory and Radiology services (X- ray, ultrasound, MRI and CT Scans).
- Prescribed physiotherapy
- Prescribed drugs and dressing.
- Referral Outpatient to specialists.
- HIV/AIDS related conditions and prescribed ARV’s to the full cover limit per family per annum.
- Newly diagnosed chronic conditions
- Pre-existing chronic conditions (including cancer)
- Pap smear for ladies and PSA for men- (for principal members only) Medical Emergency Road ambulance evacuation services.
- Rehabilitation service as per limits
- Preventive care: to include free Medical camps, Mobile Clinics for events, counselling on lifestyle and wellness
- Prescribed preventive and curative drugs/care (Including pressure stockings and clinical corset belt)
Maternity Benefits
Benefits under this cover include but not limited to; –
- Delivery/ Doctors Fees
- Routine Antenatal check-up
- Postnatal care
- Routine Immunizations (KEPI) and Baby Friendly Vaccines
- 1 st emergency caesarean section, subsequent elective CS and normal delivery
- Pre-maturity/Pre-term
- Congenital conditions
- Private room if available, for all expectant principal member and their spouses.
- The maternity benefit is available to principal members and/or their spouse only.
Dental Benefits
Benefits under this cover include but not limited to; –
Dental Consultation and Anesthetist’s fees  Dental X-rays and Root canal treatment.
- Tooth Extraction
- Scaling necessitated by a prevailing medical conditions and prescribed by a dentist Dentures necessitated by an accident/ injury Deformation surgery  Dental crowns.
Optical Benefits
Benefits under this cover include but not limited to;
- Cost of lenses and frames- members who have obtained frames will not be entitled to a replacement within one year unless necessitated by a medical condition and prescribed by an ophthalmologist.
- Prescription for ophthalmic treatment and eye lenses Ophthalmic ultrasound if prescribed by the Ophthalmologist  Surgery
Medical Emergency Road and Air Evacuation
This benefit allows for emergency transportation and transfer of sick or injured members or dependents from a place of incident or facility with inadequate care to the appropriate facility using road ambulance, fix-wing and helicopter services within East Africa (Kenya, Uganda, Rwanda and Tanzania). Air evacuation will be limited to two (2) per family annum within the policy period.
International Travel and Referral Allocations
This will be paid out where authorization has been granted for the member to travel to another country for specialized treatment which is either not available locally or is reasonably cheaper and better quality than is locally, air ticket for patient and aide and their accommodation.
A medical referral report shall be required to facilitate overseas treatment.
Al/ requests for specialized treatments outside Kenya shall be approved by the Director, Medical Services in the Ministry ofHealth.
Chronic, critical and terminal disease management
- Cancer, kidney failure, hypertension, arthritis, diabetes, HIV and AIDS, liver diseases etc.
- Covid-19 and all outbreaks of pandemics
- Drugs and substance abuse including alcoholism and associated rehabilitation Work related trauma
- Domestic violence (including Gender based violence), trauma Depression Continuous medical education
- Social counselling
- Mental health and Wellness.
SCHEME EXCLUSIONS
Active participation in war, invasion, riots or terrorism  Cosmetic treatment unless relating to an accident
Massage (except where certified as medically necessary)
- Nutritional supplements unless prescribed by a doctor as part of treatment of a deficiency
- Maternity cover for dependant children
- Self-prescribed drugs
- Treatment other than by a registered medical practitioner
- Outpatient, dental and optical co-pay of fifty shillings on each visit
- Reimbursement of costs incurred outside the appointed panel of providers unless for emergency cases, accident cases and on pre-authorization Private vaccines and travel vaccines
- Alcohol related rehabilitation
- Maternity for child dependants
- Cost of lenses and frames not prescribed by an Ophthalmologist
- Replacement of spectacle frames within the same year of cover.
- Photo chromatic and/or antiglare lenses unless prescribed by a doctor
- Cosmetic dental care — Cosmetic Crowns, Caps, Bridges, Orthodontics Dentures, self-prescribed teeth cleaning and whitening, unless necessitated by accidental injury Infertility investigation and family planning procedure expenses Replacement or repair of old dentures bridges and plates unless damage to dentures, bridges and plates becomes necessary as a result of an accident  Treatment otherwise covered by NHIF
LAST EXPENSE
The Last Expense (Funeral) cover provides a fixed amount and payable only in the event of death of the principal member to defray funeral expenses.
SERVICE PROVIDERS
The full list of accredited medical service providers for both direct access and referral medical care facilities is available at the TSC website — www.tsc.go.ke
Teachers and their dependents are required to access medical care services only from the approved panel of service providers. The Administrator shall not reimburse costs incurred outside the appointed panel of providers except for emergency cases.
Fraud and Malpractices
Teachers are strongly advised not to engage in fraudulent activities.