Basic Guide to Medical Insurance Benefits in Kenya

In the rapidly changing Kenyan medical insurance industry, it is important that you know your health plan inside out. Here are tips on how to master your health insurance policy
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(a)     Where should you obtain information about you medical insurance plan?

As a subscriber in a health plan, you will be issued with a policy handbook immediately after signing up for coverage. For those who receive medical care benefits through their employers, it is important to request the employer for a copy of the policy document. Since covered benefits differ from policy to policy and from one insurance carrier to another, you should read the document carefully and know the policy well, making notes and asking questions when necessary.

(b)     Where can you get answers for questions about your policy?

If you are covered by a policy provided through your employer, you should visit the human resources section for answers. But if you purchase the insurance plan directly, you need to contact that agent who sold you the plan. In some cases, you may have to contact the medical insurance carrier directly. Check for the contact information on the reverse side of your insurance card.

(c)     How do you know of any changes in your policy?

Usually, the insurance company will notify you of any changes in advance. It is important that you take note of any communications from your policy provider so that you avoid problems when you need medical care the most.

(d)     Does your doctor or hospital know about your benefits?

No. Your medical provider is not responsible for knowing your policy benefits, what is covered and what is not covered. Health care providers in Kenya service thousands of patients with different plans and only bill insurance just as a way of ensuring courtesy and convenience for patients. Your benefits are your responsibility, so make sure you understand them thoroughly.

(e)     Why does your doctor’s staff request for your social security number?

Your social security number will be requested to enable your doctor to administer certain aspects of your medical plan, such as getting prior authorizations for medical services. However, the law obligates the doctor or hospital to observe the highest level of security of patients’ personal information, ensuring that your information is never sold and given to unauthorized individuals.

(f)      What does prior authorization mean?

Many Kenyan medical insurance plans require permission before a patient receives medical and surgical services in order for the services to be paid. This is why your medical provider will call to request authorization for service. Nevertheless, it is your duty to know if your medical cover requires prior authorizations.

(g)     What is meant by a preferred provider or a participating provider?

A participating or preferred provider is one that has a contract in place with your medical insurance company to deliver medical and surgical care services to you for a predetermined fee schedule.

(h)     What is meant by deductibles, copayments and coinsurance?

Deductibles are a set amount of money required to be paid annually by the insured party. A Kenyan medical insurance company will not pay any of your claims until this amount is paid to the medical service provider by you (the patient). The doctor or hospital must collect this amount in full and is not allowed to adjust off any portion of this payment.

Copayments are a sum of money you are required to pay at every visit to your doctor’s clinic.

Co-insurance is the portion of medical expenses that you are responsible for after the deductible is completed and the insurance company has paid its portion. For instance, if your policy reads 80/20, it means your insurance will pay 80-percent of the claim and you will pay the remaining 20-percent. This information will be clearly availed in your policy manual as predetermined by your insurance company.

Note: Medical service providers are not allowed to adjust copayments or deductibles. It is your duty to pay these amounts.

(i)      How can you know if a medical service is covered?

Review the covered benefits in your policy handbook or call your insurance company’s customer care desk. You should also review the benefits explanation note that your insurance company sends to you after you have received medical or surgical services. The note will explain the charges, how they were reviewed and how they were paid according to your insurance policy. Any amounts you owe will match the statement provided by the medical provider, since your medical provider will obtain information from your insurance company.

(j)      When is payment expected?

Payment for your medical services will occur at the time you receive the service. You should be ready to pay for your clinic visit every time you visit your doctor. Ask the doctor’s support staff to clarify any issues with the doctor’s payment policy before you receive treatment.