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    Edu Afya comprehensive medical scheme For Students

    Hillary KangwanaBy

    EDU AFYA INFORMATION PACK

    The Ministry of Education and the National Hospital Insurance Fund (NHIF) signed a contract on 13th April 2018 to offer a Comprehensive Medical Insurance Cover for learners enrolled in all public secondary schools during their four-year study duration. As a result, the EDUAFYA Medical Scheme was rolled out on 1st May 2018.

    WHO IS ELIGIBLE?

    • Any student enrolled in a public secondary school and is fully registered in the National Education Information System (NEMIS) portal.
    • A  public  secondary  school  learner  with  a  valid Unique Personal Identifier (UPI) number generated through the NEMIS database and is registered by NHIF.
    • A learner who is fully identified by their School Principal.

    HOW TO REGISTER

    • It is the responsibility of the principal of the school to register all the learners in the NEMIS database and issue them with valid UPI numbers.
    • The process of registering a student with NHIF is automated.
    • Once a UPI number is generated, the system auto-registers the learner with NHIF and issues a unique member number.
    • Individual schools can view their learner’ NHIF numbers through their respective NEMIS portals.
    • Form Four learners shall be removed from the Scheme upon completing their Kenya Certificate of Secondary Education (KCSE) Examination.

    ACCESS TO BENEFITS

    NEMIS/UPI number OR (in the case where a learner is yet to receive a NEMIS/UPI number, a letter of introduction written by the respective School Principal or the designate.

    The letter should contain the following information:

    1. Name of learner / Age / Gender
    2. Name of school
    3. Admission number

    The letter should be duly endorsed and signed by the School Principal or the designate.

    Form One learners shall start benefiting from the Scheme immediately after they are enrolled in their respective schools (There is no waiting period for access to services for new members).

    Nature of Service What is Covered
    Out-patient ·      General  Out-patient  Services:  Outpatient  services  are provided by or on the order of a licensed clinician as a general practitioner.

    ·      Specialized Out-patient Services: Outpatient services are provided by or on the order of a clinician licensed as a specialist or consultant and to whom a member has been referred to by a general practitioner/Primary Care clinician where a member was registered.

    ·      Routine outpatient services are subject to policy terms and conditions as per the Kenya essential package for health (KEPH).

    ·      Referral for specialized services, which include the following:

    ·      Drug and Substance Abuse Rehabilitation Services

    ·      Renal services and dialysis

    ·      Specialized radiological diagnostic services

    ·      Chronic ailment services such as Diabetes and Hypertension, Ultrasound, ECG,

    ·      Cancer medical care and treatment services, include radiotherapy services, chemotherapy services or surgical intervention subject to NHIF’s preauthorization.
     
    INPATIENT Inpatient shall be on a referral basis from the outpatient Health

    Care Provider. This cover includes medical and surgical conditions that require admission.

    ·      It includes the following:

    ·      Hospital accommodation charges

    ·      Pre-hospitalization diagnostic services

    ·      Doctor’s (physician, surgeon & anesthetist) fees.

    ·      Nursing charges

    ·      Drugs/medicines,   dressings,   and    internal    surgical appliances.

    ·      Diagnostic, laboratory, or other medically necessary services

    ·      Rehabilitation services

    ·      Operating theatre services

    ·      Radiological diagnostic e.g., x-ray services, CT scan, MRI, ECG

    ·      In-patient physiotherapy.

    ·      KEPI vaccines, tetanus vaccine, Rotavirus vaccine, anti- rabies, and snake venom

     

    Daycare surgery surgical procedures that do not require an overnight stay.

     

    Dental Cover This benefit caters for outpatient dental procedures, which include, but are not limited to:

    ·      Extraction

    ·      Root canal

    ·      Dental X-ray services

    ·      Accident-related inpatient dental cases will be covered under the standard inpatient surgical benefits to the full inpatient limit.

     

    Exclusions:

    The cover does not include the cost of replacement of old dentures, bridges, plates, and orthodontic treatment of cosmetic nature
    Optical Cover An optional benefit that caters for expenses related to eye treatment, including the cost of:

    ·      Consultation

    ·      Eye testing

    ·      Prescription for ophthalmic treatment and prescription of eyeglasses

    ·      Accident-related inpatient optical cases will be covered under the standard inpatient benefits to the full inpatient limit.

     

    Exclusions:

     

    ·      Correction of refractive errors and cost of glasses and frames

    ·      Laser correction of eyesight, cosmetic antiglare and photochromatic lenses
    Emergency Road Rescue Ambulance services for transportation and transfer of a student for treatment from a place of incident or facilities. This is where adequate care is not available to the next available NHIF- declared hospital or medical facility within the territorial limits of Kenya.

     

     

    Contacts:

    Kenya Red Cross – Toll Free No: 1199

    0700 395 395

    0738 395 395

     

    Emergency Air Rescue Emergency Air Rescue Services will be provided for transportation and transfer of an injured student to an NHIF- declared facility within the territorial limits of Kenya where adequate medical care is available.

     

    Contacts:

     

    Amref Flying Doctors – 0206 992000

     

    0730 811000 | 0709 962000
    Overseas Treatment Treatment costs arise from a condition that warrants treatment not available in Kenya. Access is subject to preauthorisation from NHIF and the Director of Medical Services.

     

     

    Scope of cover

     

    ·       Treatment costs

    ·      Costs of travel and accommodation for the patient and one person accompanying the patient

    ·      On recommendation by a referring doctor, medical personnel accompanying a patient shall be covered for a period not exceeding two days.
    Last Expense NHIF shall, upon the death of a student, pay to the next of kin the amount specified in the limits upon receipt of the following documents:

    ·       Duly filled claim form;

    ·       Copy of burial permit; and

    ·       Copy of birth certificate.
    Group Life Cover NHIF shall, upon the death of a student, pay to the next of kin the amount specified in the limits upon receipt of the following documents:

    ·       Duly filled claim form;

    ·      Original burial permit;

    ·      Original death certificate, and

    ·       Original birth certificate.
    Last Expense/ Group Life Cover How to access last expense/group life cover:

     

    ·      The forms are available at the NEMIS portal or NHIF service outlet

    ·      The School Principal duly fills and signs part (I) of the form, then the County Director of Education (CDE) fills in and signs the second part (II).

    ·      The duly filled form is forwarded to the office of the Director of Secondary Education based at the Ministry of Education Headquarters.

     

    Group Personal Accident Cover NHIF shall compensate a learner involved in an accident resulting in serious or permanent disability 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 willful misconduct.

     

     

    Requirements: –

     

    ·      Duly filled claim form;

    ·      Sick off sheets;

    ·      Police abstract in case of an accident;

    ·      Medical reports;

    ·      Discharge summary; and

    ·      Copy of birth certificate.

     

    FREQUENTLY ASKED QUESTIONS

    1.    What happens to learners who transfer schools?

    As long as the learner is transferring to another public secondary school, the cover is valid. However, the learner will be exited from the cover if they transfer to a private school.

    2.     Can a learner whose parent(s) have other medical insurance covers

    benefit from Eduafya?

    Yes. All learners in public secondary schools are eligible for Eduafya cover even if their parents have alternative medical insurance.

    3.     Does a learner require to use an introduction letter?

    One of the requirements to access services is an introduction letter by the School Principal or any other designate.

    4.     How do healthcare providers identify learners?

    Facilities identify learners using the UPI and a letter of introduction from the School Principal or any other designate.

    5.        What happens if a healthcare provider does not have specific

    services or drugs required?

    The facility will be required to refer a learner to the next facility, which can handle the learner’s condition.

    6.      How does a healthcare provider handle a learner without a NEMIS number?

    The facility will not turn away a learner who does not have a UPI. However, the facility will contact NHIF to verify the learner’s details to provide services.

    7.     Does the cover work during the school holidays?

    Yes. The cover is for four (4) years or as long as one remains a public secondary school learner.

    8.      How shall a student access services during holidays?

    The learner or the guardian shall be required to provide the UPI at the facility if they need to access services during the school holidays.

    9.      How do I verify that my UPI is active with NHIF?

    This can be done by sending your UPI to 21101 on your mobile phone

    1. Why is my UPI not active when queried by hospitals? It is because your registration by the school in NEMIS is So get in touch with your principal and ask them to complete Step Two of your biodata in NEMIS.

    11.    Is one only allowed to access services in the facilities chosen by the school?

    During the school holidays, the service is portable. However, identification in facilities far away from school may be challenging if your UPI is not active when queried.

    12.          How are the last expense and group life cover claimed?

    The next of kin needs to fill in the appropriate claim form, attach all requested documents, and submit them to the Ministry of Education. Failure to attach all documents will result in a delay in the processing of claims.

    13.     Is evacuation by air included?

    All evacuations are included, although they must seek NHIF’s advice.

    14.     Can one be treated in private facilities?

    Yes, although treatment in high cost private and Level 5 hospitals is subject to pre-authorisation by NHIF.

    15.         Can one student use the UPI number of another student from the same school?

    No! This is illegal and fraudulent, and if discovered, punitive action will be taken.

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