TSC circular detailing SHA mwalimu medical cover benefits

Ref.NO: TSC/ADM/192A/VOL.X/73                                       
Date:25^th November 2025

TSC CIRCULAR NO: 29/2025

TO: ALL TSC TEACHERS

MEDICAL HEALTHCARE COVER FOR TEACHERS AND THEIR DEPENDANTS UNDER PUBLIC OFFICERS MEDICAL SCHEME FUND (POMSF)

As an initiative toward the implementation of the National Policy on Universal Health Care for the citizens, the Teachers Service Commission has contracted the Social Health Authority through the Public Officers Medical Scheme Fund (POMSF) to offer a medical cover for all teachers in their employment, together with their dependants with effect from 1^st December 2025.

i. MEMBERSHIP ELIGIBILITY

The eligibility Criteria shall be as follows:

• All teachers in active service aged 18 years up to 65 years
• One (1) legal spouse of the teacher
• Five (5) dependent children (biological/legally adopted) are eligible for cover from birth until the age of eighteen (18) years or to the age of twenty-five (25) years if residing with their parents and enrolled in a recognized postsecondary institution.
• No maximum age limit shall apply to child dependants with proven disability status.
• The maximum family size is six (6), comprising the principal member plus five (5) dependants.

2. FEE FOR SERVICE

Provision of services shall be based on “fee for service” subfect to an Individual’s limit as set out in the benefits structure below:-

3. SCHEME BENEFITS STRUCTURE

The Scheme benefits are graduated according to grading as outlined below: –

4. SCOPE OF COVER

The Medical cover shall include Inpatient, Outpatient, Dental, Optical, Maternity, funeral (including mortuary fees, hearse, coffin, wreath, and transport for immediate family of maximum 10 people), air and road evacuation allocation, (including fix wing and helicopter) international travel and referral allocations.

 a) Inpatient Benefits

This is treatment, which will require admission in and stay in a hospital or day care surgery/procedure. The benefits (paid net of SHIF rebates) under this cover include but are not limited to: –

• Doctor’s (Physician, Surgeon Anesthetist) Fee.
• ICU/HDU/CriticaI care and theatre Charges
• Drugs/Medicines, dressings and internal surgical appliance
• Pathology/Laboratoty
• X-ray, Ultrasound, ECG and Computerized Tomography, MRI Scans
• Radiotherapy and Chemotherapy
• In-Patient Physiotherapy, Hydrotherapy
• Occupational therapy
• Hospital accommodation for accompanying parent and /or guardian for hospitalized children below seven (7) years
• Medical education and Wellness program for members with preexisting and chronic conditions
• Medical Emergency Road evacuation services leading to admission
• Congenital defects/genetic disorders
• Post- Hospitalization benefit of up to two (2) weeks for other sicknesses and six (6) weeks for accident cases after discharge.
• Day care Surgery for minor surgical treatment that may not require admission
• In-vitro Fertilization (IVF)
• Renal dialysis
• Cancer Treatment and related procedures and tests.

b) Outpatient Benefits

This is treatment that does not require admission or stay in a hospital or day care. The outpatient benefits include but not limited to: –

• Routine outpatient consultations.
• Prescribed Diagnostic Laboratory and Radiology services (X, ray, ultrasound, MRI and CT Scans).
• Prescribed physiotherapy
• Prescribed drugs and dressing.
• Referral Outpatient to specialists.
• HIV/AIDS related cohditions and presctibed ARV’s to the full cover limit per family per annum.
• Newly diagnosed chronic conditions
• Pre-existing chronic conditions (including cancer)
• Pap smear for ladies and PSA for men- (for Principal members only)
• Medical Emergency Road ambulance evacuation services.
• Rehablfltätion service as per limits
• Preventive care: to include free Medical camps, Mobile Clinics for events, Counselling on lifestyle and Wellness
• Prescribed preventive and curative dnlgs/care (Including pressure stockings and clinical corset belt)

c) Maternity Benefits

Benefits under this cover include but not limited to; •

• Delivery/ Doctors Fees
• Routine Antenatal check-up
• Postnatal care
• Routine Immunizations (KEPI) and Baby Friendly Vaccines
• 1st emergency caesarean section, subsequent elective CS and normal delivery
• Pre-maturity/Pre-term
• Congenital conditions
• Private room if available, for all expectant Principal member and their spouse.

NB. The maternity benefit is available to Princtpal members and/or their Spouse only.

d)  Dental Benefits

Benefits under this cover include but not limited to; –

• Dental Consultation and Anesthetist’s fees
• Dental X-rays and Root canal treatment.
• Tooth Extraction
• Scaling necessitated by a prevailing medical conditions and prescribed by a dentist
• Dentures necessitated by an accident/ injury
• Deformation surgery
• Dental crowns.

e) Optical

Benefits under this cover include but not limited to;

• Cost of lenses and frames- members who have obtained frames will not be entitled to a replacement within one year unless necessitated by a medical condition and prescribed by an ophthalmologist.
• Prescription for ophthalmic treatment and eye lenses
• Ophthalmic ultrasound if prescribed by the Ophthalmologist
• Surgery

f) Medical Emergency Road and Air Evacuation

This benefit allows for emergency transportation and transfer of sick or injured members or dependents from a place of incident or facility with inadequate care to the appropriate facility using road ambulance, fix-wing and helicopter services within East Africa (Kenya, Uganda, Rwanda and Tanzania). Air evacuation will be limited to two (2) per family per annum within the policy period.

g) International Travel and Referral Allocations

This Will be paid out where authorization has been granted for the member to travel to another country for specialized treatment which is either not available locally or is reasonably cheaper and better quality than is locally, air ticket for patient and aide and their accommodation.

A medical referral report shall be required to facilitate overseas treatment.

h) Chronic, Critical and Terminal Disease Management

These include:

• Cancer, kidney failure, hypertension, arthritis, diabetes, HIV and AIDS, liver diseases etc.
• Covid-19 and all outbreaks of pandemics
• Drugs and substance abuse including alcoholism and associated rehabilitation
• Work related trauma
• Domestic violence (including Gender based violence), trauma
• Depression
• Continuous medical education
• Social counselling
• Mentat health and Wellness.

5. SCHEME EXCLUSIONS

The Scheme will have the following exclusions: –

• Active participation in war, invasion, riots or terrorism
• Cosmetic treatment unless relating to an accident
• Massage (except where certified as medically necessary)
• Nutritional supplements unless prescribed by a Doctor as part of treatment of a deficiency
• Maternity cover for dependent children
• Self-prescribed drugs
• Treatment other than by a registered Medical Practitioner
• Reimbursement of costs incurred outside the appointed panel of providers unless for emergency cases, accident cases and on pre authorization
• Private vaccines and travel vaccines
• Maternity for child dependants

• Cost of lenses and frames not prescribed by an Ophthalmologist
• Photo chromatic and/or antiglare lenses unless prescribed by a Doctor
• Cosmetic dental care — Cosmetic Crowns, Caps, Bridges, Orthodontics Dentures, self-prescribed teeth cleaning and whitening, unless necessitated by accidental injury
• Replacement or repair of old dentures bridges and plates unless damage to dentures, bridges and plates becomes necessary as a result of accident

6. LAST EXPENSE

The Last Expense (Funeral) cover provides a fixed amount and payable only in the event of death of the Principal member to defray funeral expenses.

7. SERVICE PROVIDERS

The full list of accredited medical service providers for both direct access and referral medical care facilities is available at the SHA website https://sha.go.ke

Teachers and their dependents are required to access medical care services only from the approved panel of service providers except for emergency cases.

8. FRAUD AND MALPRACTICES

Teachers are strongly advised to desist from engaging in fraudulent activities, which may lead to disciplinary action.

9. REGISTRATION PLATFORMS PROCESSES

Teachers can register their dependents through the following platforms:

a) Web Self-registration

On your web browser, open the SHA website- https://sha.go.ke/ click on register and start the registration process.

b) USSD Self-registration

Dial *147# on your mobile device then proceed to accept the SHA tems and conditions.

c) Assisted Enrolment

It is assisted registration done in our SHA branches, Huduma Centres and TSC County and Subcounty offices

The purpose of this Circular therefore, is to bring to your attention the provisions of the Teachers Medical cover details under Public Officers Medical Scheme Fund (POMSF).

E. J. MITEI (MS)
A.g. COMMISSION SECRETARY/CEO