Teachers’ hospital visits not limited, AON Minet clarifies.
The number of times a teacher can seek medical care in approved medical facilities should not be limited, according to the insurance company in charge of the scheme.
AON Minet Kenya CEO Sammy Muthui stated that some service providers had misinterpreted the seven-day rule in order to frustrate teachers and then accuse the insurer of mishandling them.
“We like the truth and own up when there are problems and try to solve them. Under the seven-day rule, there is no limitation to treatment… There is no limit on the number of visits but providers, because they are motivated to make more money, misinterpret the rule and then distress our teachers,” he said at a media workshop.
Muthui stated that Minet Kenya had begun disciplinary action against service providers who misinterpreted the rule.
He stated that if a member returns to the hospital within seven days for the same condition, the agreement requires that the member be attended to and that the visit not be charged to the members’ account.
This means that the teacher should never be asked to pay out of his or her own pocket.
“It is rogue service providers who want to charge capitation more times than they are allowed,” said Muthui.
“The seven-day rule should be for that incident that was treated. Even when someone is paying in cash, if you go for dressing, you do not get charged for consultation every time. We have not seen a situation where a dependent is locked out because of the seven-day rule and if there are such cases it should not happen.”
Muthui stated that in the payer-provider capitation agreement, the latter is required to provide quality services to all teachers without requiring a return to the hospital for primary healthcare unless for a different diagnosis or complication.
“Please note that there are no daily limits for outpatient services. Based on the capitation agreement with the service providers, the service provider is required to provide all the services required as per the diagnosis and the mode of treatment.”
Since 2015, Minet Kenya has been contracted by the Teachers Service Commission (TSC) to manage the teachers’ medical scheme.
Muthui stated that in order to reach out to more teachers, they have increased the number of providers, including government hospitals, so those remote areas can be served.
He stated that the insurer is in discussions with the Council of Governors to allow the insurer to accredit all government hospitals, though the challenge is that most do not have the administrative capability to perform all of the required online transactions.
“There are cases of inadequate service providers in some areas and we have to work with what is on the ground but that does not mean we can just work with everyone. Sometimes we even blacklist some providers and have about 20 cases for service providers across the country,” he said.
Minet Kenya currently works with 34 public facilities that have been added to the service providers’ panel.
In total, 577 outpatient, 367 inpatient, 338 maternity, 95 optical, and 154 dental service providers are located across all 47 counties.
Teachers used to receive a monthly medical allowance ranging from Sh954 to Sh4,412.
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However, there was a policy shift to provide teachers with a medical plan to improve their well-being.
Due to budgetary constraints, TSC chose a hybrid insurance model that included a capitation financing model and a fully insured component.
“This scheme continues to cushion 341,760 teachers and 1.7 million households against the Covid-19 pandemic,” says the TSC.