There should be no limitation in the number of times a teacher accesses medical care in approved medical facilities, insurance firm managing the scheme has affirmed.

Minet Kenya chief executive Sammy Muthui said some service providers had misinterpreted the seven-day rule 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.

Minet Kenya, Muthui said, had started taking disciplinary action against service providers who misinterpret the rule.

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He said if a member returns to the hospital within seven days for the same condition, the agreement states that the member should be attended to and the visit should not be charged to the members’ account.

This means the teacher should never be asked to pay out of 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 said that in the capitation agreement between the payer and the service provider, the latter is required to provide quality services to all teachers without warranting a return to hospital for primary healthcare unless for a different diagnosis or a complication.

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“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.”

Minet Kenya was contracted by Teachers Service Commission (TSC) to manage teachers’ medical scheme since 2015.

To reach out to more teachers, Muthui said, they have been increasing the number of providers, including government hospitals, so that remote areas can be served well.

He said the insurer is in talks with Council of Governors to allow the insurer to accredit all government hospitals though the challenge at hand is that most do no have the administrative capability to do all the online transactions needed.

“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.

Currently, Minet Kenya works with 34 public facilities which have been added to the service providers’ panel.

In all, there are 577 outpatient, 367 inpatient, 338 maternity, 95 optical and 154 dental service providers in all 47 counties.

Teachers previously earned a monthly medical allowance, which ranged from Sh954 to Sh4,412.

However, there was a policy shift to grant teachers a medical scheme to improve their welfare.

Owing to constraints in budgetary provisions, TSC settled for a hybrid insurance model namely capitation financing model and fully insured component.

“This scheme continues to cushion 341,760 teachers and 1.7 million households against the Covid-19 pandemic,” says the TSC.

Teachers’ medical service provider, AON MINET, while giving some of the challenges they face, clarified some situations where teachers will not pay ksh. 50 for consultation whenever they seek services from MINET accredited hospitals.

Without knowing, teachers have been paying the ksh. 50 prior to being attended to even in cases where they should not pay it.

MINET CEO Sammy Muthui has stressed on the seven-day rule, threatening to withdraw contracts of facilities that abuse that rule.

According to the rule, teachers who attend a particular hospital with a similar condition within a span of seven days should not pay consultation fees. However, hospitals breech this rule and get money from teachers even minus probing the last time they were there.

According to Muthui, many facilities have been blacklisted and others presently put under investigations for abusing the seven-day rule.

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“If a patient is treated for a condition and within seven days returns to the hospital to be cared for over the same ailment, they should not be charged. The member should never be asked to pay out of pocket. But we have had cases where this rule has been breached and patients asked to pay money or turned away. This is fraud and we take it seriously,” he said.

Muthui said as per the capitation agreement they signed with the service providers, health facilities are required to provide quality services to all the teachers without warranting a return to the hospital for primary healthcare, unless for a different diagnosis or a complication.

“In fact, hospitals are not supposed to even discuss the seven-day rule. They are just required to offer services as per the agreement. But we have had to blacklist many facilities for this misbehaviour,” said Muthui.

There are 607 medical service providers available on both direct and referral access.

Muthui, however, said the fraud has been detected in just a small fraction of the health facilities contracted to treat teachers and their dependents.

“We have a small number of service providers that we are already investigating and we are taking disciplinary action against them because they provide poor services that are not impressive under the scheme,” he said.

Muthui said they have embarked on a new system of rating hospitals listed under the scheme and noted that those that will post poor scores will be struck off the roll.

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“We pick facilities that are accredited by the government, but it is emerging that somewhere along the way some of them start to provide dismal services,” he said.

“We are talking about public funds and we have a duty to care. We have a legal and investigations department dealing with these. As we speak, many cases are under investigation and dozen others in court,” added Muthui.