Your out-of-pocket exposure beyond SHIF and private cover.
Uncovered exposure
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Total cover offset
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Your SHIF a year
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The space between your bill and your cover
Since October 2024 the Social Health Insurance Fund, SHIF, has replaced the old NHIF as Kenya's statutory health scheme. It funds a defined package of benefits, which is genuinely useful, but it was never designed to pay for everything. A serious admission, a specialist procedure, or a long course of treatment can run well past what SHIF and a modest private plan together will cover. The amount left over is yours to pay out of pocket, and this calculator estimates exactly that exposure so you can see whether a top-up policy is worth buying.
The logic is a subtraction. Start with the medical cost you might realistically face in a year, then take off your private cover limit and an estimate of what SHIF would contribute. Whatever remains is the uncovered gap. The tool deliberately keeps the SHIF benefit you receive separate from the SHIF contribution you pay, because confusing the two is the single biggest misunderstanding people have about the scheme.
A KES 400,000 year, partly covered
Use the defaults. You expect KES 400,000 of medical costs over the year. Your private plan caps out at KES 150,000, and you estimate SHIF would meet another KES 100,000 of the bill. Those two offsets total KES 250,000, which leaves KES 150,000 you would have to find yourself. Separately, the tool shows what you contribute to SHIF for context. On a gross salary of KES 60,000 a month, the contribution this calculator applies is 2.75 percent, which is KES 1,650 a month, or KES 19,800 over the year. Read that figure carefully: it is what you pay in, not what the scheme pays out on your behalf.
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The bar splits the KES 400,000 cost into its three parts: the slice private cover takes, the slice SHIF is estimated to take, and the dark remainder you carry yourself. The dark block is the gap a top-up would aim to close.
Contribution is not benefit, and the gap is bigger than it looks
The trap worth labouring is this: paying KES 19,800 a year into SHIF does not mean SHIF will hand you KES 19,800 of care, nor that it caps your benefit at what you paid. Statutory health funds pool everyone's money and pay according to a benefit schedule, so a low contributor can receive far more than they paid, and a high earner may receive less than they contributed. That is the point of insurance. So never plug your contribution into the SHIF-benefit box. Estimate the benefit from the actual package for the treatment you are worried about. A second common error is anchoring the expected-cost figure on routine outpatient visits; the gap that really hurts is an unplanned inpatient event, so stress-test the tool with a larger cost to see your exposure in a bad year.
Who should run this
It is for anyone deciding whether SHIF plus their employer or private plan is enough, or whether to add a top-up or a high-limit policy. A practical tip: if you have a chronic condition or a family history of costly illness, set the expected cost to a realistic worst year, not an average one, because cover is bought to survive the bad year. And remember the premium on a top-up policy qualifies for insurance relief at 15 percent, a credit the KRA allows, which softens the cost of closing the gap.
What exactly does SHIF cover?
SHIF funds a defined benefit package spanning outpatient, inpatient, maternity, and some specialised care, administered by the Social Health Authority. The detail of what is included, and the limits on each benefit, is set by the Authority and has been evolving since the scheme launched, so check the current package with the SHA rather than assuming it mirrors the old NHIF. The SHIF benefit box in this tool is your own estimate of that package, not a fixed figure.
Is the 2.75 percent contribution rate fixed?
The 2.75 percent of gross pay is the rate this calculator applies, with a stated monthly minimum, and it replaced the old banded NHIF deductions. Because SHIF is new and the surrounding rules have shifted more than once, treat the rate as the current modelled figure and confirm the latest position with the KRA, which administers it as a payroll deduction, and the SHA. The contribution has no upper cap, so higher earners pay proportionally more than under the old NHIF bands.