Healthcare Insurance; Benefits and How It Works

Health insurance is a critical pillar in the realm of modern healthcare providing financial security in the face of medical uncertainties.

In Kenya, medical covers can be exorbitantly high, especially with the advent of tough economic times and the low socioeconomic status of most Kenyans.

Having medical insurance in Kenya offers one access to essential healthcare services without the daunting burden of unmanageable costs.

What is Health Insurance?

Health insurance is an agreement between an individual and the insurance provider where the individual pays monthly premiums to the insurance company and is provided with a cover in case a medical need arises.

This article explores the various types of healthcare insurance plans that exist, and the costs that are associated with healthcare insurance and also provides insights that can serve as a compass for navigating the complex pivotal pillar of healthcare coverage.

How healthcare insurance works

Below is a summary of how healthcare insurance works but can vary:

1. You pay monthly premiums to your insurance company which is a fee for having the health plan
2. Most insurance plans have a deductible which is the amount of money you must pay out of pocket for your health plan to kick in
3. When you meet your deductible and the health plan kicks in, you start sharing costs with your plan in case of a medical need. For instance, in case of a medical emergency, your health plan may pay 80% and you pay the remaining 20% out of pocket in what is termed as coinsurance
4. Preventive care happening in the course of the year is covered 100% for example health screening, and kids’ vaccination

How do you get health insurance?

Most employers require that one have an account with an insurance company where the company makes monthly remittances to the company on behalf of the employee. Most companies advocate for government insurance like the National Health Insurance Fund (NHIF) in Kenya

The unemployed can get insurance coverage directly from a private insurance company or through the state by now paying premiums out of pocket to the insurance company they choose to take a health plan from. 

What does health insurance cover?

Most health plans cover preventive and non-preventive aspects like inpatient and outpatient services as well as emergency healthcare services. Below are examples of what your insurance company can cover through your health plan

1. Preventive visits like annual check-ups which are covered 100%
2. Vaccinations which may be covered 100%
3. Hospitalisation bill
4. Emergency services
5. Laboratory tests
6. Additional or supplemental coverage added to your care e.g. cancer care,

What does health insurance not cover?

This varies depending on the plan. Some of the services not covered include

1. Alternative medicine such as body massage and herbal healing
2. Cosmetic surgery including  plastic surgery, laser skin removal, and liposuction
3. Weight loss surgery like gastric bypass surgery or bariatric surgery may not be covered depending on the plan. However, some of these procedures may be covered if medically necessary
4. Elective surgeries especially those that doctors cannot prove the need for
5. Many health plans require prior authorization of care from your doctor for pre-approval of care by the insurance company. Failure of this pre-approval may deny you coverage
6. Experimental treatment using drugs or procedures that have no proven outcomes are not covered by your insurance company

What are the benefits of healthcare insurance?

Below are some of the benefits you get when you have a healthcare insurance

1. Low out-of-pocket costs because you share this with your insurance company
2. Free preventive care including annual checkups, and screenings (colonoscopy, lipid profile checkup, blood pressure screening).
3. Coverage for unexpected medical care which can be costly such as hospitalization or care for chronic illness like cancer. Here, your health plan covers a large portion of the costs and you cover the rest once you meet the deductible.
4. Having healthcare coverage gives you peace of mind because you don’t have to worry about out-of-pocket payments as most of the care is paid for by the insurance company. Your family also can get routine checkups at little or no cost.

When should you get health insurance?

Life is full of uncertainties and therefore you can never know what may befall you. It is therefore recommended that you get healthcare insurance even when you don’t see any risks that may lead to costly healthcare. However, you can consider getting healthcare insurance in the following circumstances

1. When you are offered a health plan by your employer
2. If you have a family to care for. With coverage, you don’t have to worry about the potential costs that you would get in case you don’t have insurance. Your family can also go for annual checkups and screenings for free and this would give you peace of mind
3. If you would not be able to meet the unexpected costs in case of an illness or injury you should get a cover
4. If you are in between jobs, consider having short-term insurance so that your family is always covered.

Top Health Insurance Providers In Kenya

The health insurance industry in Kenya has grown rapidly over the past decade. Here are some of the top health insurance providers in the country:

Jubilee Insurance – Jubilee is the largest health insurer in Kenya with over 500,000 members. They offer a wide range of inpatient and outpatient covers. Some of their top plans include the Afya Bora Plus, Afya Smart Plus and Afya Regal plans. Jubilee has a vast provider network and offers coverage across East Africa.

AAR Insurance – AAR has been in operation for over 40 years and has steadily grown its membership over the years. They are known for affordable premiums and quality service. Their top covers include Options, ARC and AM Plus. AAR has partnered with over 300 hospitals across Kenya.

Britam Health – Britam offers comprehensive inpatient and outpatient plans like Afya Sasa, Afya Bora and Afya Comprehensive. They have a large provider network with presence across major towns. Britam covers pre-existing conditions and chronic illnesses on most of its plans.

CIC Insurance Group – CIC has tailored medical covers for individuals, families and companies. Their major plans include MediPlan, MediMax and Classic MediMax. A key strength of CIC is efficient claim processing and quality customer service.

UAP Old Mutual – This company offers covers like Horizon and Tiba Ya Afya targeting individuals and families. UAP Old Mutual has an extensive provider network with over 300 local partner hospitals. They are known for innovative digital services and the Afya Pap app.

Madison Insurance – Madison offers a variety of covers including outpatient plans like Safiri Afya and Safiri Zindua and inpatient covers such as The Atlas Healthcare plan. They have partnered with over 300 hospitals across East Africa.

GA Insurance – GA Insurance provides covers for individuals, families and companies. Key plans include Optima, Optima Plus and Optima Comprehensive. GA Insurance has a reputation for efficient claims processing and large countrywide provider network.

Pioneer Assurance – Pioneer provides covers like Ongeza Afya Ya Jamii targeting SMEs and corporates and Afya Bora for individuals. They offer comprehensive wellness benefits, chronic illness coverage and post-hospitalization care.

Heritage Insurance – Heritage offers customizable medical insurance suitable for different budgets through plans like Medicover Prime, Medicover Core and Medicover Lite. They have a provider network with over 500 clinics and hospitals.

Pacis Insurance – Pacis provides covers specifically tailored for SMEs and mid-sized companies. Some of their top plans are the Pacis MediPlus and Pacis Hospital Cash covers. They offer cashless hospitalization and convenient premium payment options.

Conclusion

In Kenya, many people face economic challenges and there is also limited access to quality healthcare therefore the need for health insurance cannot be overstated.

With the rising cost of healthcare and low socioeconomic status, having healthcare insurance will provide security against exorbitant medical expenses.

Health insurance does not only provide financial security but also ensures timely access to essential medical services, preventive care, and emergency care. By alleviating the financial strain associated with medical uncertainties, health insurance empowers individuals and families to prioritize their well-being without fear of crippling healthcare costs.

Embracing health insurance in Kenya is therefore a proactive step towards the achievement of universal health coverage and securing a healthier future for all.

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