SHA Cover Limits 2026: What SHA Pays, and Where It Stops

Your SHA deduction leaves your payslip every month.

Then someone gets admitted, and the hospital hands you a bill anyway.

Here's why. SHA doesn't pay your bill. It pays a fixed tariff per service, up to a limit. Anything the hospital charges above that is yours.

Every figure below comes from the gazetted SHA tariff schedule: Legal Notice 56 of 2025, as amended by Legal Notice 78 of 2026 in May 2026. No estimates.

Table of Contents

• The One Rule That Explains Every SHA Bill
• SHA Limits at a Glance
• Outpatient and Primary Care
• Inpatient: The Daily Rate
• Maternity
• Cancer
• Kidney Care
• Imaging
• Surgery
• Optical, Dental and Mental Health
• Emergencies and Ambulance
• What SHA Never Pays For
• Where This Leaves You
• Next Steps

The One Rule That Explains Every SHA Bill

SHA works on tariffs. For each service, the law sets the amount SHA pays the hospital.

• If the hospital charges the tariff or less, you pay nothing
• If it charges more, you pay the difference
• If you hit a limit, you pay everything after it

Most limits are per household, not per person. Your whole family shares them.

SHA Limits at a Glance

Now the detail, and where each one bites.

Outpatient and Primary Care

Doctor visits, basic lab tests, X-rays, ultrasounds and medicines at Level 2, 3 and select Level 4 facilities come under the Primary Healthcare Fund.

There's no per-visit limit for you. SHA pays your Primary Care Network KES 900 per registered person per year, and the network treats you. When you register, SHA maps you to a network, and you use facilities inside it.

For people with chronic conditions, SHA also pays for a set of yearly lab tests at Level 4 to 6 hospitals, once per person per year:

More on this in SHA outpatient coverage.

Inpatient: The Daily Rate

When you're admitted, SHA pays a flat amount per day, depending on the hospital's level:

Limit: 180 days per household per year. Mental health admissions, critical care and palliative care all count toward the same 180 days.

That daily rate covers a ward bed, meals, nursing, reviews, tests and medicines during the stay. It does not cover a private ward. Private rooms are on SHA's exclusion list.

This is where most surprise bills come from. A private hospital's daily charge is often well above KES 4,480. SHA pays its rate, and the rest is yours. Full detail in SHA inpatient coverage.

Maternity

At Level 2 and 3 facilities, delivery is free for registered members. Antenatal and postnatal visits go through primary care.

Deliver at a private hospital and SHA still pays KES 10,000 or KES 30,000. If the hospital's maternity package costs more, you pay the gap. See does SHA cover maternity.

Cancer

KES 400,000 per person per year for diagnosis, staging and treatment: chemotherapy, radiotherapy, hormonal therapy, immunotherapy and cancer surgery.

Treatment must be at a Level 3 to 6 facility certified by the National Cancer Institute.

When the SHIF limit runs out, the Emergency, Chronic and Critical Illness Fund (ECCIF) is designed to continue cancer management. Here's how ECCIF works.

Kidney Care

Dialysis continues under ECCIF once SHIF limits are reached.

Imaging

Limit: 2 of each scan per household per year. A third MRI in the same household in the same year is on you.

Surgery

Every procedure has its own tariff (cataract surgery, for example, is KES 33,600). On top of that, the household gets a fixed number of procedures each year:

One household, one specialised procedure a year. If two family members need specialised surgery in the same year, plan for it.

Optical, Dental and Mental Health

Optical: eye tests are covered for everyone. Glasses only for under-18s, at KES 950, within KES 1,000 per household per year. Details in does SHA cover glasses.

Dental: fixed tariffs (KES 650 extraction, KES 1,000 basic filling, KES 1,200 cleaning) within KES 2,000 per household per year. Facilities must agree to the tariff, and the package rolls out subject to resources. Details in does SHA cover dental.

Mental health: outpatient care goes through primary care. Admissions are paid at the daily rate, within the 180 days. Rehabilitation for drug and substance abuse is KES 67,200. See SHA mental health coverage.

Emergencies and Ambulance

Two things here apply to every Kenyan resident, whether registered or not:

• Accident and emergency care for up to 24 hours: resuscitation and stabilisation after trauma, stroke, chest pain, seizures, shock, snake bites and more. After 24 hours, normal SHIF benefits apply for paid-up members.
• Ambulance evacuation through national and county ambulance call centres: KES 4,500 within a 25 km radius, KES 75 per km beyond that.

More in does SHA cover emergency care.

What SHA Never Pays For

From SHA's exclusion list:

• Private ward admission
• Cosmetic procedures
• IVF and other assisted fertility treatment
• Medicines outside the Kenya Essential Medicines List
• Professional fees above SHA's rates
• Weight management drugs and nutritional supplements
• Treatment by chiropractors, acupuncturists and herbalists
• Epidemics and pandemics

Where This Leaves You

SHA is a floor, not a ceiling. It's genuinely useful for public and mission hospitals, and for big-ticket care like dialysis and cancer.

It gets thin when:

• You use a private hospital that charges above the daily rate
• Your household shares limits like imaging, surgery and the 180 days
• You want a private room, or a specialist who bills above tariff

That gap is exactly what a private top-up covers. See which plans work best alongside SHA in best private insurance to top up SHA, or price one for your family on the health insurance calculator.

Next Steps

1. Check which level your nearest SHA hospital is. It sets your daily inpatient rate.
2. Ask your hospital for its daily ward charge before admission, so the gap isn't a surprise.
3. Count your household's shared limits before booking scans or surgery.
4. Price a top-up on the health insurance calculator.
5. Read: How to check your SHA status