Gov't caps overseas treatment for Kenyans at Ksh.500K in new criteria

In a statement, Health Cabinet Secretary Aden Duale stated that the decision followed an assessment conducted by the Benefits Package and Tariffs Advisory Panel (BPTAP) to identify the services eligible for overseas referral. 

This was guided by the legal framework including the Social Health Insurance Act, 2023, and its attendant Regulations and the Public Procurement and Asset Disposal Act.

The government, however, listed conditions for Kenyans to access overseas treatment under the new scheme. 

The process for overseas treatment mandates that the Social Health Authority (SHA) can only make payment to healthcare providers who have contracts with the authority and the beneficiary can only access the treatment outside Kenya if the services are not available locally. 

The beneficiary’s contributions must also be up to date and the treatment must be provided by a SHA- contracted health facility.

“The Benefits Package and Tariffs Advisory Panel (BPTAP) has already developed an initial list of 36 healthcare services not available in Kenya, which have been gazetted. The process of identifying additional interventions is continuous and will be guided by a comprehensive Heath Technology Assessment (HTA),” the MoH stated.

The MoH added that the referrals to overseas treatment will be subject to a peer review mechanism by the Claims Management Office to ensure medical necessity and should fall within the limits of the benefits package.

The maximum limit payable for overseas treatment is capped at Ksh.500,000, subject to review upon completion of contracting and rate negotiations with accredited providers abroad.

The Ministry of Health has directed the SHA Board of Directors to proceed with the Empanelment and Contracting of Overseas Facilities and notify the public the list of contracted facilities to facilitate the approval of overseas treatment requests in line with the regulations and MoH guidelines.

"This new framework guarantees a transparent, evidence-based and accountable system for Kenyans seeking treatment abroad, ensuring value for money and quality care," the statement read in part.