SHA: Outpatient Benefits Decoded – Your Day-to-Day Medical Coverage
Accessing Healthcare Without Hospital Admission
While inpatient coverage handles major medical events, outpatient benefits are where most teachers will interact with their medical scheme regularly. These are the services you can access without being admitted to a hospital—and the TSC-POMSF scheme’s outpatient coverage is remarkably comprehensive.
What Are Outpatient Benefits?
Outpatient benefits cover medical treatment that doesn’t require admission or overnight stay in a hospital. Think of your regular doctor visits, diagnostic tests, prescribed medications, and ongoing management of health conditions.
Routine Medical Services
Primary Care
- Routine outpatient consultations: Regular doctor visits at clinics and health facilities
- Prescribed drugs and dressing: Medications and wound care prescribed during consultations
- Prescribed physiotherapy: Physical therapy sessions when recommended by a physician
Diagnostic Services
- Laboratory services: Blood tests, urine analysis, and other diagnostic lab work
- Radiology services: Including X-rays, ultrasounds, MRI scans, and CT scans—all when prescribed by a doctor
Specialist Care
- Referral to specialists: When your primary doctor refers you to a specialist, the consultation is covered
- This enables access to cardiologists, neurologists, endocrinologists, and other specialist physicians
Chronic Disease Management
One of the scheme’s strongest features is its comprehensive approach to chronic conditions:
Newly Diagnosed Chronic Conditions
When you’re newly diagnosed with conditions like diabetes, hypertension, or asthma, the scheme covers:
- Initial consultations and assessments
- Diagnostic tests to establish baselines
- Prescribed medications to manage the condition
Pre-existing Chronic Conditions
Even if you had chronic conditions before joining the scheme, you’re covered for:
- Ongoing management and monitoring
- Regular check-ups and consultations
- Prescribed medications
- Including cancer: Full coverage for cancer management and treatment
HIV/AIDS Care
The scheme provides:
- HIV/AIDS related consultations and monitoring
- Prescribed ARVs (Antiretroviral drugs): Coverage up to the full cover limit per family per annum
- Regular viral load monitoring and CD4 counts
- Management of opportunistic infections
Preventive Care Services
The scheme emphasizes prevention alongside treatment:
Health Screening Programs
- Pap smears for women: Cervical cancer screening (Principal members only)
- PSA testing for men: Prostate cancer screening (Principal members only)
Community Health Initiatives
- Free medical camps: Access to organized health screening events
- Mobile clinics for events: On-site health services during school or community events
- Counselling on lifestyle and wellness: Professional guidance on healthy living
Preventive Medications and Devices
- Prescribed preventive and curative drugs
- Pressure stockings: For circulatory conditions
- Clinical corset belts: For back support when medically prescribed
Emergency Outpatient Services
Medical Emergency Road Ambulance Evacuation: Not all emergencies require hospital admission. The scheme covers ambulance evacuation services that lead to outpatient emergency treatment.
Rehabilitation Services
As Per Limits: Outpatient rehabilitation services are covered within the specified limits, enabling recovery and return to normal function after illness or injury.
What’s NOT Covered Under Outpatient
It’s important to know the boundaries:
- Self-prescribed drugs (must be prescribed by a registered medical practitioner)
- Private vaccines and travel vaccines
- Services from non-approved providers (except in emergencies or with pre-authorization)
Making the Most of Your Outpatient Benefits
Key Points to Remember:
- Always get prescriptions: Self-medication isn’t covered. Always consult a doctor first.
- Use approved providers: Check the SHA website (https://sha.go.ke) for the full list of accredited facilities.
- Annual limits apply: Your outpatient allocation ranges from KSh 150,000 (B5-C2) to KSh 450,000 (D5) per year for your entire family.
- Prevention is included: Take advantage of screening programs and wellness counseling—it’s part of your package.
- Chronic conditions are fully covered: Don’t avoid seeking care for ongoing conditions. The scheme explicitly covers both new and pre-existing chronic illnesses.
Real-World Application
Consider a teacher in job group C4 with diabetes (a pre-existing condition):
- Monthly doctor consultations: Covered
- Quarterly HbA1c tests: Covered
- Daily diabetes medication: Covered
- Annual eye examinations (diabetes-related): Covered under outpatient
- Nutrition counseling: Covered
- Blood pressure monitoring: Covered
All of this falls within the KSh 225,000 annual outpatient allocation, with additional support available through the chronic disease management program.
Next up in Post 5: Maternity benefits—everything expectant parents need to know.
