PRESENTATION ON TEACHERS MEDICAL COVER UNDER PUBLIC OFFICERS MEDICAL COVER (POMSF)

BRIEF ON TSC MANDATE

The Teachers Service Commission, TSC, is an  independent constitutional commission established under  Article 237(1)  with the  mandate to: register trained teachers, recruit and  employee registered teachers, assigned teachers employed by the commission for the  service in any public school  or  institution,  promote and  transfer teachers, exercising disciplinary control over teachers, terminate the employment of teachers, review the standard of education and training of persons entering the teaching service, review the demand for and the supply of teachers and advice the  National Government on matters relating to the teaching profession.

BACKGROUND ON THE TEACHER’S MEDICAL COVER

The Teachers Medical Cover was set up in July 2015 under Minnet as the administrator by the  Commission to  replace the  medical allowance. Over time the Commission has improved on the  management of the cover by:

•  Setting up a Contract  Implementation team;
• Devolving the monitoring of the contract implementation at various levels i.e counties; and
• Progressively reviewed the cover scope over time to align with the needs of teachers.

CHALLENGES OVER THE PERIOD OF IMPLEMENTATION  OF THE MEDICAL COVER

Despite the continuous improvement the following challenges persisted:

• Limited empaneled hospitals across the country;
• Insurance model;
• Rejection of admission requests  forcing teachers to use  their own resources;
• Lengthy procedures in Pre-authorization or approval for admissions and  discharges;
• Inadequate specialists in most  facilities, especially outpatient services;
• Inadequate supply of original quality drugs;
• Poor management of Chronic conditions;
• Few optical and  dental care providers empaneled;
• Restricted  cover  for dependants (moreso for teachers with more dependants than  the  maximum  provided by the  employer);
• Lengthy onboarding criteria; and
• One fit benefit structure.

COMMISSION’S  ACTION TO MITIGATE THE CHALLENGES

Following enactment of the regulations of the  POMSF the  Commission intends to engage the Social Health Authority to manage the  teachers Medical Cover with the existing covers limits under the Public Officers Medical Scheme Fund.

ACTIONS TO MITIGATE CHALLENGES

TEACHERS BENEFIT PACKAGE BY THE COMMISSION UNDER POMSF

SCOPE OF COVER

1. Principal Member

2. Declared  spouse

3. Declared children (up to 5 children):

• Up to 21 years of age

• A maximum of (25) years of age if wholly dependent on  the  principal  member and enrolled in full-time post-secondary education;

• A child with disability who is wholly dependent on the principal  member – in this case there shall be no  age limit for coverage of a person with disability declared as a dependent of the principal member

• Additional children above the five covered can be included at an additional premium paid by the principal  member.

REGISTRATION PLATFORMS & PROCESSES (SELF)

Web Self-registration

• On your web browser, open the SHA website- https://sha.go.ke/

• click on register and start  the registration process.

USSD Self-registration

• Dial *147# on your mobile  device then  proceed to accept the SHA terms  and conditions.

Assisted Enrolment

• It is assisted registration done in our SHA branches, Huduma Centres  and TSC County and Subcounty offices

Registration of Teenage & Underage Mothers

Registration now  possible for teenage mothers at SHA branches,  Huduma Centres and TSC County and Subcounty offices.

REGISTRATION & UPDATING OF BENEFICIARIES

• Spouse-ID of spouse and proof  of marriage
• Child-Birth  notification/Certificate
• Adopted Child-Adoption Order

A child  for who  the contributor is a Guardian-Will, Deed or court order or other document recognized under the Children’s Act

• Person with Disability-ID & Certificate of Registration from National  Council for Persons with Disabilities
• Persons under lawful custody-Prison  admission number or remand identification number of copy of ID
• Child in conflict with the law-admission number of the  children’s remand home,  rehabilitation institution or borstal institution or Child’s  birth certificate

CHANGE OF SPOUSE

• A 30-day  waiting period applies when a member changes their declared spouse for the first time before  the new spouse becomes eligible for services.
• For any subsequent spouse change, a 6-month waiting period applies before eligibility for services
• In case the change is due  to death of a spouse, the waiting  period does  not apply.

HOW TO ACCESS MEDICAL BENEFITS

Accessing Outpatient services

i. All scheme beneficiaries shall access outpatient services on fee for service within their limits which are on family shared basis.

Requirements at the Healthcare Provider
A copy of the National  Identification Card with Biometric and/or OTP verification.

Accessing Inpatient Services

All scheme beneficiaries shall access inpatient services on fee for service within their limits which are on family shared basis.

Documents required at point of service

i. A copy of the spouse’s ID.

ii. Copy of birth certificate for a child or copy of birth notification for child below six (6) months or copy of adoption certificate.

iii. A copy  of registration Certificate  with the  National Council for Persons with Disability

iv. A  letter of proof that the child  is  enrolled in a  full-time learning institution for children above  21 years will be required.

TEACHERS BENEFIT PACKAGE BY THE COMMISSION UNDER POMSF

Comprehensive Benefit Package Summary

1. Outpatient & Inpatient Cover
2. Maternity package
3. Dental and Optical
4. Radiology services
5. Renal Dialysis
6. Oversees treatment
7. Annual medical checkup
8. Chronic Illness
9.Tests for donors
10. Evacuation services
11. Drug and substance abuse rehabilitation

SHA BENEFITS PACKAGE DETAILS

Outpatient Cover

Cover includes; Consultation with a General Practitioner & Specialist, basic laboratory investigations,  drugs & dispensation, health education, wellness and counselling,

Physiotherapy services and the following vaccines; KEPI vaccines, Rota virus vaccine, Anti- rabies and Anti-snake venom.

Inpatient Cover

Cover includes hospital stay with health care diagnosis, consultation, accommodation/bed charges,  nursing care, diagnostic laboratory tests, radiology examinations, physician’s, surgeon’s, anaesthetist’s,  physiotherapist’s fees, operating theatre charges, specialist consultations or visits, prescribed medications and dressings.

Maternity & Reproductive Health

• Antenatal care, delivery through both Normal  Delivery or Caesarian Section and Postnatal care.
• Family planning services
• Management of postnatal and neonatal complications within applicable inpatient limits

Surgical Package

Includes all surgical procedures(minor, major and specialized) including transplants with an exception of cosmetic surgeries.

Organ Donor Testing

Pre-test costs for the kidney donor identification up to a maximum  of two (2).

Renal  Dialysis

It caters  for hemodialysis for the needed care plan including Specialists’ reviews, nursing  and dialysis services, intra-care and dispensed medications, routine laboratory tests,  nutrition, counselling and follow up.

Rehabilitation Package: Drug and Substance Abuse

Includes rehabilitation treatment for persons addicted to harmful or hazardous psychoactive substances.

Radiology Package

Includes ALL diagnostic imaging services e.g. CT-Scan, MRI, Mammography, EEG, ECG

Orthopedic and Other Appliances

Covers devices  such as hearing aids, prosthetics, and mobility aids (e.g., crutches, wheelchairs)

Oncology Package

Includes treatment for cancer  patients using radiotherapy, chemotherapy, hormonal therapy and immunotherapy.

Dental Package

Covers consultations, orthodontics, root  canal treatment, post-root canal crowns, fillings, X-rays, and extractions (including  surgical extractions).

Optical Package

Includes cost of consultation with ophthalmologist/optometrist, eye testing, glasses for refractive errors, optical frames and lenses.

Emergency Care

Covers emergency evacuation(road & air) for principal  members and dependants to facilities with adequate care, ensuring timely access to critical treatment.

Foreign Treatment

Cover for treatment costs  arising from a condition that  warrants treatment that  is not available in Kenya. Cover includes;

• Treatment cost for patient and organ donor where applicable,
• Cost of travel and accommodation for the patient and one person accompanying the patient,
• Cost of travel and accommodation for medical  personnel accompanying a patient on recommendation by the referring  Doctor  for a period not exceeding two days.

Overseas Treatment

• The process for accessing overseas or foreign treatment is as follows:-

1. Referral letter from the treating doctor.

2. A potential donors must  be a registered SHA member

Travel Insurance

Emergency cover is  provided for a principal member who is on official duty out of the country for a period  not exceeding 6 weeks.

SHA shall provide travel insurance cover on request to a Principal Member travelling  outside the country.

The following are the requirements for issuance  of travel insurance:

1. Clearance letter from the authorizing officer;

2. Cover letter to SHA from the respective employer;

3. Copy of Bio-Data page of the Passport/ Travel Pass Document;

4. Proof of travelling date.

Last expense

Caters for funeral expenses upon the death of the principal member.

Requirements

• Duly completed claim form

• Copy of burial permit

• Copy of deceased’s ID

Specialized Treatment

• Specialized  services will be on referral basis.

• The healthcare provider is required to seek preauthorization for specialized services.

• These services shall be on fee for service basis.

• Services available in SHA Empaneled and Contracted Facilities

Services Covered

• Renal Dialysis & Renal Transplant
• Optical & Dental
• Chronic Illness e.g., Diabetes, Hypertension
• Radiological Tests e.g., MRI & CT Scan
• Oncology
• Orthopaedic Appliances
• Drug and  Substance Abuse Rehabilitation
• Overseas Treatment

Annual Medical Checkup

Provides comprehensive annual health  assessments for the principal member and spouse including;

• Full history and physical examination
• Blood pressure testing;
• Random  or fasting  blood sugar testing;
• Cancer screening; Pap Smear and Prostate Specific Antigen  (PSA) test
• Electrocardiograph (ECG);
• Lipid Profile
• Stool Analysis
• Urinalysis
• Breast ultrasound or mammogram;
• Liver function  test;
• Kidney function  test;
• Body Mass Index (BMI) test and nutritional advice.

EXCLUSIONS

•   Treatments at non-contracted facilities or unauthorized referrals,  to maintain quality and cost control.

•   Treatments by chiropractors, acupuncturists, or herbalists, as these are outside  the scheme scope.

•   Self-prescribed treatments, services, or commodities, to prevent misuse.

•   Expenses for non-conventional therapies including weight management drugs,  nutritional supplements, stop-smoking  aids, or domestic remedies unless prescribed as part of medical  treatment.

•   Costs from clinical trials or research environments, to focus on proven treatments.

Additional Benefits out of the arrangement

THE FUNDS

• PRIMARY HEALTHCARE FUND
• SOCIAL HEALTH INSURANCE FUND
• EMERGENCY, CHRONIC AND CRITICAL ILLNESS FUND
• PRIMARY HEALTHCARE FUND
• INDIVIDUALS CONTRIBUTE PREMIUMS
• GOVERNMENT FUNDING
• Benefits accessed by all registered members to SHA
• Benefits accessed only  by paid-up members
• Accident and Emergency services accessible to all Kenyan residents

PHC Package

• Outpatient – KES 900 per annum per beneficiary

• Optical Services – Limit of KES 1,000  per annum (children < 18 years)

SHIF PACKAGE

Inpatient
KES 2,240  – 4,480  per day of admission up to 180 days per household

Maternity
Normal delivery – KES 10,000 •    C- section – KES 30,000 •    Anti-D Serum  – KES 6,000

Oncology
KES 400,000 per member per annum

Renal Care

•    Renal Dialysis – KES 10,650  upto 2 sessions per week

•    Peritoneal Dialysis – KES 85,200 per month

•    Pre-transplant recipient evaluation – Limit of KES. 150,000 per household

•    Recipient surgery – KES 700,000

•    Donor nephrectomy – KES 168,000

•    Post-renal replacement therapy – Limit of KES 200,000 per household

Medical Imaging

•    MRI – KES 11,000

•    Mammography – KES 3,000

•    CT Scans   – KES 6,900

•    Fluoroscopy – KES 4,000

•    CT Angio – KES 8,000

•    Echocardiograms (ECHO) – KES 3,500

•    Specialized ultrasounds (Dopplers) – KES 5,000

•    Electroencephalograms (EEGs) – KES 8,000  for a child and KES 5,000 for an adult.

•    2 per household per annum

Surgical Package

•    Minor Surgery  up to KES 145,600

•    Major Surgery  up to KES 280,000

•    Specialized Surgery   up to KES 1,120,000

Outpatient

• Essential diagnostic laboratory investigations for Diabetes, Hypertension, Sickle-cell & COPD/Asthma(once per person per annum)

  Diabetes – KES 4,300

  Sickle cell – KES 6,800

  Hypertension – KES 2,850

  COPD/Asthma – KES 700

Overseas Treatment
KES 500,000

Mental Wellness
Drug & Substance Abuse Rehabilitation – KES 67,200

Critical Care Services – ICU/HDU
KES 28,000 per day of admission up to 12 days

Oncology
KES 150,000 per beneficiary

Accident & Emergency
Up to KES 107,633

Ambulance Services
Intra Metro  (25 km Radius) – KES 4,500

> 25 km – KES 75 per km

Interplay between the additional Package and POMSF  Benefits

SHIF: Public officers are enrolled  in SHIF like all employed Kenyans, but POMSF shall acts as  a top-up scheme. When SHIF benefits are exhausted (e.g., hospital bills exceeding SHIF cover), POMSF steps  in to provide additional protection for civil servants and their dependents.

ECCIF Role: Government-funded; provides coverage for emergency, chronic, and catastrophic illnesses (e.g.,  accident  &  emergency,  cancer   treatment,  ICU/HDU).  Accessible  to  all  Kenyans. Public  officers  benefit from ECCIF first, like all citizens, for life-threatening conditions. POMSF bridges any financing gaps  not   fully  covered by ECCIF, ensuring public officers and their dependents have full access  to advanced treatment.

PHCF Role:  Provides basic outpatient and promotive health services at the  primary  level, fully funded by government. Accessible to all Kenyans registered under SHA. POMSF only supplements by covering  enhanced or specialized services once  basic care pathways are exhausted