SHA Coverage for Chronic Conditions: Diabetes, Hypertension & More

Living with diabetes means daily medication. Hypertension requires regular monitoring. Asthma needs inhalers on hand.

Chronic conditions are expensive. Does SHA help?

Here's exactly what SHA covers for ongoing health conditions.

Table of Contents

• What Counts as a Chronic Condition?
  • Conditions Covered Under SHA
• How SHA Chronic Care Works
  • Registration Process
  • Registration Steps
• What SHA Covers for Chronic Conditions
  • Outpatient Chronic Care
  • Medication Coverage
  • Inpatient Chronic Care
• Diabetes Coverage Under SHA
  • Outpatient Services
  • Medications
  • What You Might Pay Out of Pocket
• Hypertension Coverage Under SHA
  • Outpatient Services
  • Medications
  • Complications Covered
• Mental Health Coverage
  • Outpatient Mental Health
  • Inpatient Mental Health
  • Covered Medications
• Dialysis Coverage
  • What's Covered
  • Frequency Limits
  • Transplant
• Using SHA for Chronic Care: Practical Steps
  • Step 1: Get Diagnosed Properly
  • Step 2: Establish Care Routine
  • Step 3: Medication Management
  • Step 4: Monitor and Follow Up
• Common Problems and Solutions
  • Problem 1: "My Medication Isn't Covered"
  • Problem 2: "The Hospital Says I'm Not Registered for Chronic Care"
  • Problem 3: "I'm Being Asked to Pay for Covered Services"
  • Problem 4: "Waiting Times Are Too Long"
• Tips for Managing Chronic Conditions Under SHA
  • 1. Build a Relationship with Your Provider
  • 2. Keep Your Own Records
  • 3. Know Your Medications
  • 4. Plan for Costs
  • 5. Consider Private Top-Up
• SHA vs Private Insurance for Chronic Care
• Frequently Asked Questions
• The Bottom Line
• Next Steps

What Counts as a Chronic Condition?

Chronic conditions are long-term health issues that require ongoing management. They don't go away with treatment — they need continuous care.

Conditions Covered Under SHA

How SHA Chronic Care Works

Registration Process

To access chronic care benefits, you must:

1. Be diagnosed by a registered medical practitioner
2. Register your condition with SHA
3. Get a chronic care card/code in the SHA system
4. Access care at SHA-accredited facilities

Registration Steps

Step 1: Diagnosis Visit a SHA-accredited facility. Doctor diagnoses your condition through:

• Physical examination
• Laboratory tests
• Medical history

Step 2: Documentation Hospital submits to SHA:

• Diagnosis confirmation
• Treatment plan
• Required medications

Step 3: Approval SHA verifies and registers you for chronic care benefits. Usually takes 1–2 weeks.

Step 4: Ongoing Care You can now access chronic care services at any SHA-accredited facility.

What SHA Covers for Chronic Conditions

Outpatient Chronic Care

Medication Coverage

SHA covers medications on their formulary (approved drug list).

Common covered medications:

Important: Not all medications are covered. Newer, brand-name drugs may require out-of-pocket payment.

Inpatient Chronic Care

If your chronic condition leads to hospitalization:

Diabetes Coverage Under SHA

Diabetes is one of the most common chronic conditions in Kenya. Here's what's covered:

Outpatient Services

Medications

What You Might Pay Out of Pocket

• Premium insulin brands
• Continuous glucose monitors
• Insulin pumps
• Diabetes-specific supplements
• Advanced testing beyond routine

Hypertension Coverage Under SHA

Outpatient Services

Medications

Complications Covered

If hypertension leads to:

• Stroke — emergency and rehabilitation covered
• Heart attack — full cardiac care covered
• Kidney disease — nephrology care covered
• Heart failure — ongoing management covered

Mental Health Coverage

SHA has expanded mental health coverage compared to NHIF.

Outpatient Mental Health

Inpatient Mental Health

Covered Medications

Dialysis Coverage

For chronic kidney disease requiring dialysis:

What's Covered

Frequency Limits

SHA typically covers 2–3 dialysis sessions per week. More frequent dialysis may require out-of-pocket payment.

Transplant

Kidney transplant is covered under SHA, including:

• Pre-transplant evaluation
• Surgery
• Post-transplant care
• Immunosuppressant medications (with limits)

Using SHA for Chronic Care: Practical Steps

Step 1: Get Diagnosed Properly

• Visit a SHA-accredited hospital
• Get full diagnostic workup
• Ensure condition is documented in SHA system

Step 2: Establish Care Routine

• Register with a primary care facility
• Maintain regular appointments
• Get referrals for specialists as needed

Step 3: Medication Management

• Get prescriptions from SHA-accredited providers
• Collect medications from network pharmacies
• Know which meds need out-of-pocket payment

Step 4: Monitor and Follow Up

• Keep all medical records
• Track your condition markers (BP, blood sugar, etc.)
• Report any changes to your provider

Common Problems and Solutions

Problem 1: "My Medication Isn't Covered"

SHA covers medications on their formulary. Newer drugs may not be included.

Solutions:

1. Ask your doctor for a covered alternative
2. Request a substitution form if no alternative exists
3. Pay out of pocket for specific non-covered medications
4. Appeal to SHA with doctor's letter explaining medical necessity

Problem 2: "The Hospital Says I'm Not Registered for Chronic Care"

Your condition needs to be registered in the SHA system.

Solutions:

1. Visit a SHA facility with your diagnosis documents
2. Request they submit chronic care registration
3. Follow up after 1–2 weeks
4. Call SHA helpline if issues persist

Problem 3: "I'm Being Asked to Pay for Covered Services"

This can happen due to system issues or facility practices.

Solutions:

1. Confirm service should be covered (check with SHA app)
2. Ask for itemized bill
3. Pay and keep receipts
4. Submit reimbursement claim to SHA
5. Report the facility if it's systematic

Problem 4: "Waiting Times Are Too Long"

SHA facilities can be crowded.

Solutions:

1. Book appointments in advance where possible
2. Go early in the morning
3. Consider private top-up insurance for faster service
4. Use chronic care clinics (often less crowded than general outpatient)

Tips for Managing Chronic Conditions Under SHA

1. Build a Relationship with Your Provider

Regular care from someone who knows your history is better than seeing a new doctor each time.

2. Keep Your Own Records

Track:

• Medications and dosages
• Test results (BP, blood sugar, etc.)
• Appointment dates and notes
• Questions for next visit

3. Know Your Medications

• Generic names (not just brand names)
• Dosages
• When and how to take them
• Side effects to watch for

4. Plan for Costs

Even with SHA:

• Some medications cost extra
• Premium options require payment
• Budget for health expenses monthly

5. Consider Private Top-Up

If you need:

• Newer medications
• Faster access
• Specific specialists
• Private hospital care

Private insurance alongside SHA fills these gaps.

SHA vs Private Insurance for Chronic Care

Best approach: SHA for base coverage, private top-up for enhanced coverage

Frequently Asked Questions

Can I register multiple chronic conditions? Yes. Each condition should be registered separately with appropriate documentation.

What if I'm diagnosed with a new condition? Get documentation from your doctor and submit for registration. SHA will add it to your profile.

Are pre-existing conditions covered? Yes, if you've been a SHA contributor. There's no pre-existing condition exclusion for SHA unlike private insurance.

How often can I refill medications? Typically monthly. Some chronic medications can be prescribed for 2–3 months at a time.

What about traditional/alternative medicine? Not covered under SHA. Only conventional medical treatments apply.

The Bottom Line

SHA covers chronic conditions including:

• Diabetes
• Hypertension
• Asthma
• Mental health conditions
• Kidney disease
• And more

What you need to do:

1. Register your condition in the SHA system
2. Get care at SHA-accredited facilities
3. Know which medications are on formulary
4. Keep records of your treatment
5. Consider private top-up for enhanced coverage

Chronic conditions are manageable. SHA helps with the basics — ensure you're using all available benefits.

Next Steps

1. Check your SHA status: How to Check Your SHA Registration Status
2. Verify your chronic condition is registered
3. Find SHA-accredited facilities near you
4. Consider: Best Private Insurance to Top Up SHA
5. Read: Complete SHA Benefits Guide