SHA Outpatient Coverage: Doctor Visits, Tests, and Medications

You feel sick. Maybe it's a persistent cough, a nagging headache, or you need your blood pressure checked.

Do you go to the hospital? What will SHA cover?

Here's your complete guide to outpatient services under SHA.

Table of Contents

• What Is Outpatient Care?
• SHA Outpatient Coverage Overview
• How Outpatient Coverage Works
  • Step 1: Visit SHA-Accredited Facility
  • Step 2: Present Your ID
  • Step 3: Receive Care
  • Step 4: Direct Billing
• Outpatient Limits
  • Typical Outpatient Limits
• What's Covered
  • Doctor Consultations
  • Laboratory Tests
  • Imaging Services
  • Medications
  • Minor Procedures
  • Chronic Condition Care
• What's NOT Covered (Outpatient)
• Using Outpatient Services Effectively
  • Tip 1: Choose the Right Facility
  • Tip 2: Bring Your ID
  • Tip 3: Start with Primary Care
  • Tip 4: Ask About Formulary
  • Tip 5: Track Your Usage
  • Tip 6: Get Referrals Properly
• Common Outpatient Scenarios
  • Scenario 1: Routine Doctor Visit
  • Scenario 2: Blood Tests for Annual Checkup
  • Scenario 3: Specialist Referral
  • Scenario 4: Chronic Condition Follow-Up
• When You Exceed Your Limit
  • What Happens
  • Options If You Exceed
• Outpatient at Different Facilities
  • Level 2–3 Health Centers
  • Level 4 Hospitals (Sub-county)
  • Level 5 Hospitals (County Referral)
  • Level 6 (National Referral)
• Common Questions
  • "Can I see any doctor under SHA?"
  • "Do I need approval before tests?"
  • "What if my medication isn't covered?"
  • "Can I choose my doctor?"
  • "How do I check my remaining limit?"
• SHA Outpatient vs Private Insurance
• The Bottom Line
• Next Steps

What Is Outpatient Care?

Outpatient care is medical treatment where you're not admitted to the hospital overnight.

Examples:

• Doctor consultations
• Laboratory tests
• X-rays and scans
• Collecting medication
• Minor procedures
• Follow-up appointments

Not outpatient:

• Surgery requiring admission
• Overnight hospital stay
• ICU care
• Extended treatment

SHA Outpatient Coverage Overview

SHA provides outpatient benefits as part of your coverage.

How Outpatient Coverage Works

Step 1: Visit SHA-Accredited Facility

Go to a SHA-accredited hospital, health center, or clinic.

To find facilities:

• Check SHA Super App
• Call SHA helpline
• Visit sha.go.ke

Step 2: Present Your ID

No card needed. Your National ID is your verification.

The facility checks your SHA status electronically.

Step 3: Receive Care

• See the doctor
• Get tests ordered
• Collect medications

Step 4: Direct Billing

The facility bills SHA directly. You pay nothing for covered services (within your limits).

Outpatient Limits

Your outpatient coverage has limits. Once you exceed them, you pay out of pocket.

Typical Outpatient Limits

Note: Specific limits vary. Check your SHA profile for your exact limit.

What's Covered

Doctor Consultations

General Practitioner (GP):

• Primary care visits
• Diagnosis and treatment
• Referrals to specialists
• Sick notes/medical reports

Specialists (with referral):

• Cardiologist
• Dermatologist
• Orthopedist
• Gynecologist
• ENT
• Neurologist
• Others

Referral process:

1. See GP first
2. GP assesses and refers if needed
3. Take referral letter to specialist
4. Specialist visit covered

Laboratory Tests

Imaging Services

Note: Advanced imaging (CT, MRI) may require pre-authorization and have annual limits.

Medications

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

How it works:

1. Doctor prescribes medication
2. Pharmacy checks if it's on SHA formulary
3. If yes → covered
4. If no → you pay out of pocket (or doctor suggests alternative)

Common covered medications:

• Antibiotics (generic)
• Pain relievers
• Blood pressure medications
• Diabetes medications (basic)
• Asthma inhalers
• Allergy medications
• And many more

Usually NOT covered:

• Brand-name when generic available
• Newest/expensive drugs
• Vitamins and supplements
• Cosmetic medications

Minor Procedures

Chronic Condition Care

If you have a registered chronic condition (diabetes, hypertension, asthma, etc.):

Requirement: Register your chronic condition with SHA first.

What's NOT Covered (Outpatient)

Using Outpatient Services Effectively

Tip 1: Choose the Right Facility

Not all facilities are SHA-accredited. Verify before you go.

Best practice: Save 2–3 nearby accredited facilities in your phone.

Tip 2: Bring Your ID

Your National ID is your insurance card. No ID, no verification.

Tip 3: Start with Primary Care

Don't jump to specialists unnecessarily. GPs can handle most issues and provide referrals when needed.

Benefit: Faster service, appropriate care level.

Tip 4: Ask About Formulary

Before accepting a prescription, ask: "Is this medication covered by SHA?"

If not, ask if there's a covered alternative.

Tip 5: Track Your Usage

Know how much of your outpatient limit you've used. Don't be surprised when you're asked to pay.

Check via: SHA Super App or facility

Tip 6: Get Referrals Properly

For specialist care:

1. Get written referral from GP
2. Take referral to specialist
3. Ensure specialist visit is documented

Without proper referral, specialist visit may not be covered.

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Common Outpatient Scenarios

Scenario 1: Routine Doctor Visit

You have: Flu symptoms, cough, fever

Process:

1. Go to SHA facility
2. Present ID
3. See GP
4. Get diagnosis
5. Receive prescription
6. Collect medication from pharmacy
7. Pay nothing (within limits)

Scenario 2: Blood Tests for Annual Checkup

You need: General health screening

Process:

1. Visit facility
2. See doctor, request tests
3. Doctor orders: CBC, sugar, lipids, kidney, liver
4. Go to lab, have blood drawn
5. Return for results
6. Covered under outpatient

Scenario 3: Specialist Referral

You have: Persistent knee pain

Process:

1. See GP first
2. GP examines, provides referral to orthopedist
3. Book specialist appointment
4. Specialist may order imaging
5. Specialist consultation and imaging covered
6. Treatment plan developed

Scenario 4: Chronic Condition Follow-Up

You have: Registered diabetes

Process:

1. Regular visit to SHA facility
2. Blood sugar check
3. Medication refill
4. Counseling if needed
5. All covered under chronic care

When You Exceed Your Limit

What Happens

Once you use your full outpatient limit:

• You pay out of pocket
• SHA won't cover additional outpatient services that year
• Limit resets annually

Options If You Exceed

1. Pay out of pocket for remaining year
2. Use private insurance if you have top-up cover
3. Wait for emergency (emergencies have separate consideration)
4. Manage usage better next year

Outpatient at Different Facilities

Level 2–3 Health Centers

Services:

• Basic consultations
• Simple lab tests
• Medication dispensing
• Minor procedures

Best for: Routine care, minor issues

Level 4 Hospitals (Sub-county)

Services:

• More comprehensive consultations
• Full lab services
• Basic imaging
• Minor surgery

Best for: Moderate health issues, some specialist care

Level 5 Hospitals (County Referral)

Services:

• Specialist consultations
• Advanced lab services
• Full imaging (CT, MRI)
• Complex procedures

Best for: Specialist needs, complex cases

Level 6 (National Referral)

Services:

• Super-specialist care
• Highly complex procedures
• Rare condition treatment

Best for: Complex cases requiring highest level care

Note: Generally need referral for higher levels. Going straight to Level 6 for minor issues wastes resources.

Common Questions

"Can I see any doctor under SHA?"

Only at SHA-accredited facilities. Private clinics may not be accredited.

"Do I need approval before tests?"

Basic tests: No. Advanced imaging (CT, MRI): May need pre-authorization.

"What if my medication isn't covered?"

Ask for a generic or alternative. If none available, you pay out of pocket.

"Can I choose my doctor?"

At larger facilities, you may request a specific doctor. At smaller centers, you see whoever is available.

"How do I check my remaining limit?"

Use the SHA Super App or ask at the facility.

SHA Outpatient vs Private Insurance

Best approach: SHA for base coverage + private top-up for better access and limits.

The Bottom Line

SHA outpatient coverage includes:

• Doctor consultations
• Lab tests
• Imaging
• Medications (from formulary)
• Minor procedures
• Chronic care

To use effectively:

1. Go to SHA-accredited facilities
2. Bring your National ID
3. Start with primary care
4. Get proper referrals
5. Track your limit usage
6. Ask about formulary medications

Outpatient care is often your most-used benefit. Understand it. Use it wisely.

Next Steps

1. Find SHA-accredited facilities near you
2. Download the SHA Super App
3. Check your outpatient limit
4. Save your ID (it's your insurance card)
5. Explore: Complete SHA Benefits Guide
6. Consider: Best Private Insurance to Top Up SHA