The Teachers Service Commission (TSC) claims to have addressed the issues with the previous teachers’ medical plan and to have emphasized a number of processes it has implemented under the current contract.
Pre-authorization for outpatient patients and the controversial 7-day rule’s restrictions on hospital visits were eliminated in September 2022, according to Commission Secretary and CEO Dr. Nancy Macharia.
“Teachers seeking medication on outpatient are free to visit the hospital any time they fall sick,” Dr. Macharia told the Members of Parliament (MPs) when she appeared before the Parliamentary Committee on Education on February 14, 2023.
Initially, as per the capitation agreement between the payer and the service provider, the service provider was to provide health services without warranting a return to hospital for primary healthcare unless for a different diagnosis or a complication.
If a member returned to hospital within 7 days for the same condition, the agreement said the treatment shall not be charged on the member account.
As part of tendering, the commission requested for 300 health facilities, including missionary, private and public hospitals, and a panel of specialist doctors in all counties. This was to deal with inadequacy of qualified doctors in most empaneled hospital facilities and limited number of empaneled medical service providers.
Mandatory approval from Bliss Hospital has been removed, with teachers now free for referrals to and from other health facilities, but within the list of those approved under the new contract.
“All contracted medical service providers shall be free to directly refer medical requests to other health facilities within the list of medical service providers where a medical doctor has determined or recommended,” she said.
However, TSC had to explain why teachers needed referrals from Bliss Hospital in the previous contract, with the commission’s deputy director in charge of finance Franklin Choge saying Bliss Hospital was a ‘capacitator’.
“The scheme has components of insurance and capitation and Bliss is the master capacitator,” Choge explained to the legislators.
For the record, Bliss was the only hospital where teachers went for referrals in the old contract. On the lengthy procedures that were witnessed in pre-authorization, the commission said that the new contract provided different timelines for various pre-authorizations for admission and discharge for inpatients.
Under the new contract, pre-authorization for treatment or admission should be within 10 minutes, for discharge within three hours, admission of new members should be within 24 hours after notification, dealing with complaints on delayed service shall be within 2 hours, dealing with complaints on availability and accessibility of medical health facilities shall be dealt with in 7 days, and uploading of dependents shall be within 6 hours.
The commission also notes that the challenge of inadequate cover on preterm/and premature babies has been fully addressed in the new cover under the inpatient cover for the principal members.
The consortium members or any of the Contracted Service Providers (CSP) have now been required to use biometric identification systems as the main member identification tool in order to avoid the use of One-Time-Pin (OTP).
“Registration under the biometric platform will be continuous throughout the contract period to ensure that all teachers access the medical cover,” said the TSC boss.
Under the new cover, the use of the biometric platform is to ensure only eligible beneficiaries are registered on the scheme’s biometric programme and the USSD platform provided to forestall any fraud.
Regarding different amounts charged as co-pay, the commission negotiated a fixed amount of Ksh 100 as co-pay per outpatient visit per individual for dental, optical and specialized doctor for consultation services.
TSC has, however, noted that the co-pay is not charged on outpatient hospital visits for medical services, repeat visits for service within 14 days from the date of previous visit, and when picking medication for chronic conditions which do not require consultations with the doctor.
Minet Kenya Insurance Brokers Limited won the tender to provide the medical cover for a period of three years effective December 1, 2022 to November 31, 2025 being the lowest evaluated bidder on the Capitation Financing Model at a contract price of Ksh 53.58 billion.
