The cover has been effective from May 2018
It covers all children in public secondary schools in Kenya.
Eligibility- Who qualifies for the EduAfya Cover
- A student in a public secondary school in Kenya.
- The student should be registered in the NEMIS database.
- The student should be registered with NHIF.
- Only the Student shall be covered under the scheme and not a dependant.
- Form four (4) Students shall be exited from the scheme upon completion of KCSE exam.
Registration For EduAfya Cover
Once a UPI number is generated the system auto registers the student with NHIF and issues a member number.
The school can view the student’s NHIF number through the NEMIS portal.
NHIF has began the process of biometric registration of the students.
Biometric registration of students will be conducted in the school.
ACCESS TO BENEFITS OF THE SCHEME
All students will access benefits in the any of the health care providers contracted by NHIF.
To access services at the health care provider, the student shall present a letter of introduction written, duly endorsed and signed by the respective school principal or the designate.
The letter should contain the following information:
- Name of student / Age / Gender
- Name of School
- Admission number
There is no waiting period for access to service for new students.
How to Access outpatient Services
- The students can access outpatient services in any of the health care providers contracted by NHIF for EDUAFYA.
Requirements at the health care provider:
- Letter from the principal ( during the school term)
- A copy of the birth certificate and the UPI number(during school holidays/away from school)
How to Access Inpatient Services
The students can access inpatient services on referral basis at the contracted health care providers.
Requirements at health care providers:
- A copy of the birth certificate.
- A letter of introduction from the principal ( during the school term).
Provisions of EDUAFYA
- Outpatient & Inpatient Cover
- Dental & Optical
- Overseas treatment
- Radiology Services
- Drug & Substance Abuse Rehabilitation
- Chronic Illness Renal Dialysis
- Evacuation Services
- Last expense
- Group life
- Group personal accident
Out Patient Cover
Consultation with a General Practitioner & Specialists, Basic laboratory investigations, drugs & dispensation, health education, wellness and counselling, physiotherapy services and the following vaccines: Anti – rabies and Anti –Snake venom.
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.
Includes all surgical procedures including transplants with an exception of cosmetic surgeries.
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 a student addicted to harmful or hazardous psychoactive substances.
Oncology Package Includes treatment for cancer patients using radiotherapy and chemotherapy.
Includes ALL diagnostic imaging services e.g. CT-Scan, MRI Orthopedic and Other Appliances Crutches, prosthetics, Hearing Aids e.t.c.
Includes cost of consultation with ophthalmologist/optometrist, eye testing and prescription for ophthalmic treatment.
Frames and glasses shall be access in NHIF-contracted Government facilities or any other contracted facility approved by NHIF subject to pre-authorisation.
Includes dental consultation, orthodontics, root canal, dentures, Cost of filling, X-rays and Extractions including surgical extractions together with anaesthetics fees, hospital and operating theatre cost.
Dental treatment and care will be accessed at NHIF contracted Government facilities or any other contracted facility approved by NHIF subject to pre-authorisation.
Local emergency road ambulance service
Emergency evacuation, transportation & transfer of a sick member or dependent for treatment at the nearest NHIF declared hospital.
Service provider: Eplus (Kenya Red Cross)
TOLL FREE LINE 1199.
Emergency air rescue service
Transportation and transfer of an injured member to an NHIF contracted facility where adequate care available within the territorial limits of Kenya.
Service provider: AMREF Flying Doctors Rescue: +254 (0) 206 992000 | +254 (0) 730 811000 | +254 (0) 709 962000
Cover for treatment costs arising from a condition that warrants treatment that is not available in Kenya.
- 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.
- Reimbursement of claims related to emergency treatment incurred while the principal member is temporarily outside the country on official duty if the period is not exceeding six weeks at any one visit.
Overseas treatment also caters for emergency services for a scheme member who is out of the country on school related activities.
The period of cover does not exceed 6 weeks
This is covered in form of travel insurance.
Letter from Ministry of Education/clearance letter Passport Travel dates/air tickets.
Features of travel insurance
- Medical Expenses
- Medical Evacuation Expenses
- Repatriation of Mortal Remains/Burial Expenses
- Coffin Expense Accompanying Family Member
COVID 19 Treatment
Scheme Members shall access Covid-19 medical treatment and care at Government designated Covid-19 treatment centres in Government of Kenya.
Where a Scheme Member is unable to access Covid-19 treatment and care at a GoK health facility, the Member shall be referred to a Government designated Covid-19 treatment centre approved by NHIF, subject to pre-authorisation.
Specialized services will be on referral basis.
The health care provider is required to seek preauthorization
Specialized services are available in NHIF contracted Facilities.
- Renal Dialysis & Renal Transplant.
- Optical & Dental.
- Radiological tests e.g., MRI & CT Scan.
- Orthopaedic and other medical appliances e.g. wheelchairs, crutches, pressure stockings e.t.c.
- Drug and Substance Abuse Rehabilitation.
Treatment costs for beneficiaries for a condition that warrants treatment not available in Kenya will be covered subject to pre authorization by NHIF.
The process is as follows:-
- Referral letter from the treating doctor.
- Approval from the Director General, Ministry of Health.
- A letter from the school principal.
- A potential donor must be a registered NHIF member.
- Travel & accommodation for the patient & one accompanying person.
- Travel & accommodation for the organ donor.
- Treatment costs.
LAST EXPENSE (FUNERAL COVER).
NHIF shall upon death of a student, pay to the next of kin the amount specified in the limits upon receipt of the following documentation;
- Duly filled claim form;
- Copy of burial permit; and
- Copy of birth certificate.
In addition to the Last Expense, NHIF shall upon death of a student, pay to the next of kin the amount specified in the limits upon receipt of the following documentation;
- Duly filled claim form;
- Original burial permit;
- Original death certificate; and
- Original birth certificate.
GROUP PERSONAL ACCIDENT
NHIF shall compensate a learner who is involved in an accident resulting in serious or permanent disablement while at school or participating in a school related activity.
A learner is not entitled to compensation if an accident is caused by deliberate and wilful misconduct.
- Duly filled claim form;
- Sick off sheets;
- Police abstract in case of accident;
- Medical reports;
- Discharge summary; and
- Copy of birth certificate.
- Treatments arising from non-accredited health facilities and/or un-authorized referrals
- Cosmetic surgery or beauty treatment & cosmetic procedures including complications arising from them
- Massage (except where certified as a necessary part of treatment following an accident or illness).
- Treatment by chiropractors, acupuncturists and herbalists
- Self-prescribed procedures
- Medical costs related to/or incurred in research environment & clinical trials
- Treatments not covered under the contract-stay overseas more than six weeks.
- Laser eye surgery for correction of refractive errors.
Where can these benefits be accessed?
- Public healthcare providers
- Faith-based healthcare providers
- Private healthcare providers
NB: List of declared health care providers is available in the NHIF Website.
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- Toll Free Line :0800720601
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