There should be no limitation in the number of times a teacher accesses medical care in approved medical facilities, insurance firm managing the scheme has affirmed.

Minet Kenya chief executive Sammy Muthui said some service providers had misinterpreted the seven-day rule to frustrate teachers and then accuse the insurer of mishandling them.

“We like the truth and own up when there are problems and try to solve them. Under the seven-day rule, there is no limitation to treatment… There is no limit on the number of visits but providers, because they are motivated to make more money, misinterpret the rule and then distress our teachers,” he said at a media workshop.

Out of pocket

Minet Kenya, Muthui said, had started taking disciplinary action against service providers who misinterpret the rule.

He said if a member returns to the hospital within seven days for the same condition, the agreement states that the member should be attended to and the visit should not be charged to the members’ account.

This means the teacher should never be asked to pay out of pocket. “It is rogue service providers who want to charge capitation more times than they are allowed,” said Muthui.

“The seven-day rule should be for that incident that was treated. Even when someone is paying in cash, if you go for dressing, you do not get charged for consultation every time. We have not seen a situation where a dependent is locked out because of the seven-day rule and if there are such cases it should not happen.”

Muthui said that in the capitation agreement between the payer and the service provider, the latter is required to provide quality services to all teachers without warranting a return to hospital for primary healthcare unless for a different diagnosis or a complication.

“Please note that there are no daily limits for outpatient services. Based on the capitation agreement with the service providers, the service provider is required to provide all the services required as per the diagnosis and the mode of treatment.”

Minet Kenya was contracted by Teachers Service Commission (TSC) to manage teachers’ medical scheme since 2015.

To reach out to more teachers, Muthui said, they have been increasing the number of providers, including government hospitals, so that remote areas can be served well.

He said the insurer is in talks with Council of Governors to allow the insurer to accredit all government hospitals though the challenge at hand is that most do no have the administrative capability to do all the online transactions needed.

Medical allowance

“There are cases of inadequate service providers in some areas and we have to work with what is on the ground but that does not mean we can just work with everyone. Sometimes we even blacklist some providers and have about 20 cases for service providers across the country,” he said.

Currently, Minet Kenya works with 34 public facilities which have been added to the service providers’ panel.

In all, there are 577 outpatient, 367 inpatient, 338 maternity, 95 optical and 154 dental service providers in all 47 counties.

Teachers previously earned a monthly medical allowance, which ranged from Sh954 to Sh4,412.

However, there was a policy shift to grant teachers a medical scheme to improve their welfare.

Owing to constraints in budgetary provisions, TSC settled for a hybrid insurance model namely capitation financing model and fully insured component.

“This scheme continues to cushion 341,760 teachers and 1.7 million households against the Covid-19 pandemic,” says the TSC.