The Ministry of Health through the Social Health Authority (SHA) has explained that SHA’s coverage is based on gazetted tariffs that are published on the authority's website.
In a statement on Sunday, December 15, SHA disclosed that the tariffs ensure sustainable healthcare coverage and equitable access while maintaining a shared responsibility model.
However, the authority noted that in cases where hospital charges exceed specified limits, SHA beneficiaries may be required to pay out of pocket.
"In light of recent concerns regarding the extent of SHA coverage, we wish to clarify the framework governing SHA’s benefits and tariffs. The Ministry of Health confirms that SHA’s coverage is based on gazetted Tariffs to the Benefits, published in November 2024.
"These tariffs (available at the SHA website at https://sha.go.ke/resources/categories/7) ensure sustainable healthcare coverage and equitable access while maintaining a shared responsibility model. In cases where hospital charges exceed specified limits, beneficiaries may be required to make co-payments," Principal Secretary Medial Services Harry Kimtai explained.
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Regarding the Intensive Care Unit (ICU) and High Dependency Unit (HDU) services, Kimtai stated that the provider payment mechanism (PPM) is a per diem rate that depends on the facility visited.
He maintianed that SHA provides ICU and HDU coverage of up to Ksh3,360 per day in Level 4 facilities, Ksh3,920 per day in Level 5 facilities, and 4,480 per day in Level 6 facilities.
The PS further disclosed that each household has a limit of 180 days per year for access rules and that members can access services from empaneled and contracted Level 4-6 facilities.
"The members will top up any amount that exceeds the above cover limit (co-pay). The cover limit is the same for public, faith-based, and private facilities," Kimtai stated.
He noted that SHA is proactively addressing emerging challenges to ensure seamless access to all services and the Ministry of Health is in the process of constituting a committee to review tariffs and benefits.
"Based on feedback from stakeholders gathered over time, the committee will be expected to review and provide practical solutions and make informed recommendations. The committee report will address both short-term and long-term interventions to ensure SHA sustainability and responsiveness to the needs of Kenyans," Kimtai remarked.
