Health Insurance Regulations (2000 Revision) THE HEALTH INSURANCE LAW, 1997

Health Insurance Regulations (2000 Revision) Supplement No. 3 published with Gazette No. 5 of 28th February, 2000. THE HEALTH INSURANCE LAW, 1997 (15 of 1997) THE HEALTH INSURANCE REGULATIONS (2000 Revision) Revised under the authority of the Law Revision Law (1999 Revision). The Health Insurance Regulations, 1997 made the 19th August, 1997 and approved by affirmative resolution of the Legislative Assembly on the 5th September, 1997, consolidated with the Health Insurance (Amendment) (Indigent Persons) Regulations, 1999 (sic) made the 2nd December, 1998 and approved by affirmative resolution of the Legislative Assembly on the 12th April, 1999. Consolidated and revised this 25th day of January, 2000. 1 Health Insurance Regulations (2000 Revision) 2 Health Insurance Regulations (2000 Revision) HEALTH INSURANCE REGULATIONS (2000 Revision) ARRANGEMENT OF REGULATIONS 1. Citation 2. Definitions 3. Prescribed health care benefits 4. Insurance for high risk insurance persons 5. Health care for indigent uninsurable and indigent partially uninsurable persons 6. Premiums 7. Cover 8. Claims 9. Payment of claims 10. Maximum benefits 11. Renewal of contract 12. Insurer ceasing to be approved 13. Records 14. Documents to be submitted to the Authority 15. Identification card 16. Inspectors 17. Powers of inspectors 18. Employer to maintain records 19. Offences 20. Government employees 21. Seamen and veterans 22. Indigents 23. Determination of disputes First Schedule: Prescribed health care benefits Second Schedule: Claim form for a compulsorily insured person Third Schedule: Minimum information required to be included in the health insurance identification card 3 Health Insurance Regulations (2000 Revision) 4 Health Insurance Regulations (2000 Revision) HEALTH INSURANCE REGULATIONS (2000 Revision) 1. These regulations may be cited as the Health Insurance Regulations (2000 Citation Revision). 2. In these regulations - Definitions “dependant” means- (a) the spouse of an employee; and (b) a child of the employee not covered under another health insurance contract; “episode of illness” includes any period during which a person receives medical treatment for an illness within sixty days of any previous treatment for the same illness; and “fees” include any fees or charges prescribed to be paid by patients of health care facilities for treatment, nursing, accommodation, attendance, food, dressings, drugs, medicines or other supplies or services rendered to such patients by the health care facilities. 3. (1) Subject to subregulations (2) to (5), the health care benefits to be Prescribed health care covered by the standard health care insurance contract are- benefits (a) the in-patient benefits specified in Part 1 of the First Schedule; and (b) the out-patient benefits specified in Part 2 of the Second Schedule. (2) Subject to subregulation (5), the in-patient benefits specified in Part 1 of the First Schedule may be provided at a health care facility in the Islands or at an overseas health care facility. (3) The out-patient benefits specified in Part 2 of the First Schedule shall be limited to out-patient benefits provided in a health care facility in the Islands. (4) Part 3 of the First Schedule specifies benefits which are not required to be included in a standard health insurance contract. (5) Subject to regulation 9, where a compulsorily insured person is required to receive treatment at an overseas health care facility and the Chief 5 Health Insurance Regulations (2000 Revision) Medical Officer or two registered medical practitioners have provided written confirmation that such treatment cannot be provided at a health care facility in the Islands and that such person requires the treatment as alleged, the compulsorily insured person shall be entitled to claim and receive such usual and reasonable costs for any in-patient benefits received. Insurance for high risk 4. Where a person applies to an approved provider to obtain insurance for a insurance persons high risk insurance person, the approved provider may- (a) decline to provide insurance for that high risk insurance person; (b) provide insurance cover under a standard health insurance contract at the standard premium; (c) provide cover under a standard health insurance contract at an increased premium to take into account the increased risk being assumed by the approved provider provided that such premium shall not exceed two hundred per cent of the standard premium; or (d) provide cover under a standard health insurance contract but subject to an exclusion or limitation of cover in respect of the medical condition which has caused the applicant to become a high risk insurance person. Health care for indigent 5. (1) The Government shall, in order to cover medical costs for indigent uninsurable and partially uninsurable persons and indigent partially uninsurable persons, collect from- indigent uninsurable persons (a) each approved provider, five dollars per month of each premium charged by the approved provider under each standard health insurance contract effected by such provider in respect of an insured with no dependants; and (b) each approved provider, ten dollars per month of each premium charged by the approved provider under each standard health insurance contract effected by such provider in respect of an insured with dependants. (2) The medical services that shall be available under this regulation- (a) in the case of an indigent uninsurable person, shall be equal to those provided under a standard health insurance contract; and (b) in the case of an indigent partially uninsurable person, shall, in respect of the medical condition which is the subject of the exclusion or limitation in his standard health insurance contract, be equal to those provided under a standard health insurance contract, and, subject to subregulation (3), shall be available at a government health care facility. 6 Health Insurance Regulations (2000 Revision) (3) Where a government health care facility is unable for any reason to provide medical services to an indigent uninsurable person or an indigent partially uninsurable person, that person may be referred to any other health care facility in the Islands or to an overseas health care facility by the Chief Medical Officer. (4) Payments collected under subregulation (1) shall be paid into a segregated fund which shall be administered by an administrator to be appointed by the Authority acting upon the advice of the Financial Secretary. (5) The administrator of the fund shall have power to invest any part of moneys in the fund in such securities as may be approved by the Authority. (6) An auditor approved by the Authority shall make interim examinations of the receipts and payments of the fund and shall submit to the Authority a report on each such interim examination upon the completion of the examination. (7) The administrator of the fund shall cause proper accounts of the fund to be maintained in such form as the Authority may direct. (8) The accounts of the fund shall be audited annually by an auditor approved by the Authority. (9) Where the Authority considers it necessary and in the public interest, it may, by notice in writing to the approved providers, vary the amount to be paid into the fund and such notice shall be published in the Official Gazette. (10) The administrator shall, from time to time and upon the request of the Director of Health Services, disburse monies from the fund to the Director of Health Services for the payment of any medical costs accrued on behalf of an indigent uninsurable person or an indigent partially uninsurable person. 6. (1) Each approved provider shall, prior to its first effecting any standard Premiums health insurance contract, notify the Authority of its standard premium for such contracts and shall, within fourteen days, notify the Authority of any change to such premium. (2) Premiums shall become due on the first day of the month for which they are payable. (3) The part of the employee’s premium payable by the employee under sections 5 and 6 shall be paid at regular weekly or monthly periods during his employment. 7 Health Insurance Regulations (2000 Revision) 7. (1) Subject to these regulations, the minimum period of cover provided Cover under a standard health insurance contract shall be one month. (2) Where a premium is paid by the employer in respect of any employee, that employee and his dependants, if any, shall be covered under the standard health insurance contract for the month for which the premium is paid notwithstanding that during the course of that month his employment may be terminated or he otherwise ceases to be compulsorily insured. (3) Where an employee takes up employment in the course of a month the effective day for the purpose of determining liability of his employer under section 3 shall be the first day of employment, except that, where the employee is already insured for the month in which the employment begins under a contract of insurance effected by his previous employer, the effective day shall be the first day of the month next following the first day of employment. (4) Cover under a standard health insurance contract ceases on the first day of the month next following the date of the termination of employment except that, in accordance with section 12, if the employee does not become insured under any other employer, cover under the contract shall continue for a period of one month from the date of termination of employment. (5) The provisions of this regulation shall apply with the necessary changes in respect of the dependants of the employee. Claims 8. (1) All claims by a compulsorily insured person shall be made in the Form in the Second Schedule. (2) A claim submitted under this regulation shall be accompanied by- (a) a detailed receipt from a health care facility or a registered medical practitioner showing the payment made to the health care facility or the registered medical practitioner by or on behalf of the insured person or such other proof of the costs incurred by that person; and (b) such information relating to the benefits received by the insured person as the approved provider may reasonably require for the purpose of determining the claim. Payment of claims 9. (1) Subject to subregulation (3), a compulsorily insured person shall be required to pay for any benefit in Part 1 of the First Schedule received by him at a health care facility or a registered medical practitioner, twenty per cent of the fee for that benefit. 8 Health Insurance Regulations (2000 Revision) (2) An approved provider shall pay in respect of each person insured compulsorily with that provider for any benefit in Part 1 of the First Schedule received by that person at a health care facility or registered medical practitioner, eighty per cent of the fee for that benefit. (3) Notwithstanding subregulations (1) and (2), an approved provider shall be liable during each calendar year to pay all fees charged after the first $2,500 for any benefits to an insured person under Part 1 of the First Schedule subject to the annual limit specified in regulation 10. (4) An approved provider shall be liable to pay- (a) the whole of the cost of the benefit specified in paragraph 2 of Part 2 of the First Schedule; and (b) not more than the amount specified in relation to the other benefits in Part 2 of the First Schedule. 10. An approved provider shall not be liable to pay on behalf of each Maximum benefits compulsorily insured person- (a) for each episode of illness, more than $25,000 in medical fees; (b) during each calendar year, more than $100,000 in medical fees; and (c) during the life of an insured, more than $1,000,000 in medical fees. 11. (1) Subject to subregulation (2), a standard health insurance contract shall Renewal of contract provide that it continues in force for a period not exceeding twelve months provided that the premium is paid. (2) Subregulation (1) is without prejudice to an approved provider’s right to terminate a standard health insurance contract in accordance with section 12. 12. (1) If- I1n9s9u9r eRr ecveiassioinng to be approved (a) the licence of an approved provider is revoked or suspended for any reason by the Governor in Council under the Insurance Law (1999 Revision); or (b) an approved provider withdraws from the provision of health insurance, the approved provider shall not be relieved of any liability in respect of any standard health insurance contract in force at the date of such revocation, suspension or withdrawal. 9 Health Insurance Regulations (2000 Revision) (2) Where a circumstance specified in paragraph (a) of subregulation (1) occurs and an approved provider is unable to provide cover for the duration of a contract, the administrator of the segregated fund for indigent uninsurable and partially uninsurable persons may, within one month of the occurrence of such a circumstance, pay from the funds for benefits received by any person previously insured with that approved provider under a standard health insurance contract and who is not yet insured with another approved provider. Records 13. (1) An approved provider shall keep a record in respect of each person insured by that approved provider under a standard health insurance contract. (2) A record kept in accordance with subregulation (1) shall be produced to the Authority upon request. Documents to be 14. An approved provider shall submit to the Authority at least once every submitted to the twelve months a certificate signed by an auditor stating- Authority (i)the amount of premium collected under each standard health insurance contract effected by that provider; and (ii)that the approved provider has complied with regulation 5. Identification card 15. (1) An approved provider shall, within two weeks of the making of a standard health insurance contract, issue an identification card to each person insured by the approved provider under that standard health insurance contract. (2) An identification card shall contain such minimum information as is specified in the Third Schedule. (3) An approved provider who fails to provide an identification card in accordance with subregulation (1) is guilty of an offence and liable on summary conviction to a fine of two thousand dollars. (4) A health care facility or registered medical practitioner shall not be required, except in the case of an emergency, to provide any medical benefits to any person who fails or refuses to show his identification card. Inspectors 16. (1) The Authority may, by notice in the Gazette, appoint inspectors for the purposes of the Law. (2) Each inspector shall be issued with an identification card prepared and signed by the Authority which shall contain a photograph of the inspector. Powers of inspectors 17. (1) An inspector shall, for the purpose of performing his functions under these regulations, have power- 10 Health Insurance Regulations (2000 Revision) (a) to enter, without previous notice, at all reasonable times, any premises or place liable to inspection under the regulations and the Law; (b) to examine the records maintained under regulation 18 and to make such examination and inquiry as may be necessary for ascertaining whether the provisions of the Law are being or have been complied with; (c) to examine, with respect to any matter under the Law or these regulations on which he may reasonably require information, every person whom he finds in any such premises or place; and (d) to exercise such other power as may be necessary for carrying the Law into effect. (2) The premises and places liable to inspection under this regulation are any premises or place where the Authority has reasonable grounds to suspect that any person who is or ought to be insured under the Law is employed. (3) Every inspector on applying for admission to any premises or place for the purposes of these regulations shall, if so required, produce the identification card issued to him under regulation 16. 18. Every employer shall maintain employment and earnings records relating to Employer to maintain each employee showing- records (a) the name, address, sex and date of birth of each such employee; (b) the dates of commencement and termination of employment; (c) if such employee is married and has children, the name and address of his spouse and children and if the spouse is employed, the name and address of the employer of the spouse; (d) the name of the approved provider with whom a standard health insurance contract has been effected; and (e) the amount deducted monthly from the wages, salary or other remuneration of each employee in respect of health insurance. 19. (1) An employer who fails to maintain records in accordance with Offences regulation 18 is guilty of an offence and liable on summary conviction to a fine of two hundred and fifty dollars. (2) Whoever- (a) wilfully delays or obstructs an inspector in the exercise of any power under these regulations; or (b) refuses or neglects to answer any question or to produce any document or record when required to do so by an inspector, 11 Health Insurance Regulations (2000 Revision) is guilty of an offence and liable on summary conviction to a fine of two hundred and fifty dollars. Government employees 20. (1) The Government may, in respect of each employee and his dependants in the following categories, effect, with an approved provider, a health insurance contract which shall provide benefits not less than those provided by the Government in accordance with Chapter 18 of General Orders prior to the 31st January, 1998- (a) officers in pensionable offices or on probation to such offices; (b) officers serving under local and overseas contracts; (c) group employees and officers serving in temporary offices for a period of three years or more; and (d) public office pensioners. (2) In respect of any other government employee, the Government may effect with an approved provider in respect of each such employee and his dependants a standard health insurance contract. Seamen and veterans 21. (1) Government may effect with an approved provider in respect of- (a) a seaman over the age of fifty-five or his unemployed spouse; (b) a widow of a seaman; (c) a member of the Veterans’ Association and his unemployed spouse; or (d) a widow of a former member of the Veterans’ Association, a health insurance contract which shall provide benefits similar to those available to the persons specified in regulation 20(1) provided that such benefits shall be available only at a government health care facility. (2) Subregulation (1) does not apply to a seaman who first went to sea after the 31st December, 1984 or to a seaman who was at sea for a period of three years or less. (3) A person specified under this section shall, prior to obtaining any health care service at a government health care facility, present proof of his membership or the membership of her spouse of either the Veterans’ and Seamen’s Society of Cayman Brac and Little Cayman, the Cayman Islands Seamen’s Association or the Cayman Islands Veterans’ Association. Indigents 22. Government may effect with an approved provider on behalf of indigent persons a health insurance contract which shall cover the benefits available to those persons specified in regulation 20(1). 12 Health Insurance Regulations (2000 Revision) 23. (1) Where a person disputes a matter under a standard health insurance Determination of contract including a claim to a benefit, he may apply to the Authority by notice in disputes writing requesting a determination of the matter, and such application shall state briefly the nature of the matter. (2) On receipt of a notice under subregulation (1), the Authority may request such further information and documents as it deems necessary to assist it in determining the matter. (3) Where the Authority disallows a claim under a standard health insurance contract or determines a question adversely to the applicant, it shall notify the applicant in writing of its decision, the reasons for the decision and the right of appeal under section 18. 13 Health Insurance Regulations (2000 Revision) Regulation 3 FIRST SCHEDULE PRESCRIBED HEALTH CARE BENEFITS Part 1 In-patient benefits 1. Accommodation and meals up to thirty days per episode in a semi-private room or, where medically necessary, in an intensive care unit. 2. Physicians’, specialists’ and surgeons’ services including ambulant surgery. 3. Anaesthesia, use of operating room and recovery rooms. 4. Use of all in-patient services of any health care facility. 5. Full nursing service up to thirty days per episode. 6. Standard surgical supplies including oxygen, surgical appliances and implants. 7. Medication and drugs. 8. Use of physiotherapy, inhalation and other rehabilitative therapy facilities. 9. X-ray and ultrasound services. 10. Laboratory and pathological studies (including overseas referrals of such studies by registered medical practitioners). Note: Where the Chief Medical Officer and one other registered medical practitioner other than the attending medical practitioner certifies that a patient must receive the said benefit for more than the thirty days maximum, such patient may claim payment for the cost or part of the cost of the benefit in excess of thirty days. Part 2 Out-patient benefits 14 Health Insurance Regulations (2000 Revision) 1 Visits to a registered medical practitioner including a routine physical check- up, routine laboratory tests, radiological and pathological studies subject to a limit of one hundred dollars each calendar year. 2. Haemodialysis. 3. Emergency medical services including medication, drugs and ambulance services subject to a maximum of four thousand dollars each calendar year. 4. Ante-natal services at a health care facility in the Islands subject to a maximum of five hundred dollars per pregnancy. Note: For the purposes of this part “emergency” means a sudden or unexpected occurrence or event causing a threat to life or limb. Part 3 Benefits which may be excluded under a standard health insurance contract Benefits will not be provided in connection with- 1. The treatment of any illness or injury which occurred prior to the commencement of the standard health insurance contract, unless the illness or injury or other pre-existing condition was- (a) fully disclosed in writing; and (b) not excluded by the approved provider upon acceptance of the proposal for the standard health insurance contract. 2. Consultations in connection with and treatment for, infertility including in- vitro fertilisation, artificial insemination and other experimental services. 3. Consultations in connection with and treatment for, sexual dysfunction or sex change procedures. 4. Contraceptive drugs or devices or sterilisation. 5. Treatment for any illness caused by or injury sustained in a war (declared or undeclared) or while a person was in active military service in any country. 6. Treatment for injury sustained during hazardous activities including hang- gliding, sky-diving, parachuting, ballooning, flight in ultra-light aircraft and scuba diving. 7. Treatment for obesity or weight reduction. 15 Health Insurance Regulations (2000 Revision) 8. Treatment for illness or injury arising from or associated with a psychiatric condition, drug or alcohol abuse, self-inflicted injuries, and sexually transmitted diseases. 9. Treatment for any illness or injury arising from or connected with the Human Immunodeficiency Syndrome. 10. Dental treatment, dental X-rays, extractions, fillings, and general dental care except dental surgery for the excision of impacted teeth or a tumour or cyst or treatment for injury to sound natural teeth. 11. Treatment which, in the opinion of the approved provider, is not medically necessary. 12. The supply or fitting of eye glasses, contact lenses or hearing aids. 13. Marital counselling, including therapy for marital difficulties and family counselling. 14. Occupational therapy. 15. Charges for - (a) rest cures, (b) custodial, hospice or geriatric care, (c) periods of legally enforced quarantine or isolation; or (d) services received in hydros, or nature cure clinics. 16. Home nursing. 17. Services of an intern or resident doctor unless billed by a health care facility. 18. The rental or purchase of orthotic devices or appliances except where those devices or appliances are required to be permanently fastened to an orthopaedic brace. 19. Cosmetic surgery. 20. Rental or purchase of exercise equipment or similar non-medical equipment and other items for personal comfort. 21. Charges which the insured has no legal obligation to pay or for which no charge would have been made if the insured had no health insurance cover. 22. Treatment, medicine or other supply which is experimental. 16 Health Insurance Regulations (2000 Revision) For the purposes of this Part - (a) “cosmetic surgery” means surgery performed primarily to improve a person’s physical appearance or to treat a mental condition through change in the body’s appearance, other than surgery for the repair or treatment of an injury or a congenital bodily defect to restore bodily functions; (b) “experimental” in relation to - (i)treatment, medicine or other supply, means treatment, medicine or other supply which is still a part of a research programme and which has not been approved by the Health Practitioner’s Board; and (ii)medicine or other supply, means medicine or other supply which is not included in the British National Formulary or the Physician’s Desk Reference unless it has been approved for use in the Islands by the Chief Medical Officer; (c) “medically necessary” in relation to treatment medicine or other supply, means treatment, medicine or other supply which is- (i)appropriate to the diagnosis or treatment of the insured’s illness; (ii)consistent with accepted medical or professional standards of practice; (iii)not primarily for the personal comfort or convenience of the insured, his family, his physician or other health provider; and (iv)the most appropriate level of treatment or medicine that can safely be provided to the insured and which, in the case of in- patient care, cannot be provided safely on an out-patient basis; and (d) “semi-private room” means a room in a health care facility that is equipped to accommodate two to four persons. 17 Health Insurance Regulations (2000 Revision) SECOND SCHEDULE regulation 8 CLAIM FORM FOR A COMPULSORILY INSURED PERSON 18 Health Insurance Regulations (2000 Revision) THIRD SCHEDULE regulation 15 MINIMUM INFORMATION REQUIRED TO BE INCLUDED IN THE HEALTH INSURANCE IDENTIFICATION CARD Name of insured: Policy number: Certificate number: Name of employer: Name of dependant: Hospital registration number (where applicable): This card is issued as a means of identifying the Insured’s Health Insurance Policy. For verification of coverage and questions on benefits, please contact the following insurance company- Name of insurance company: Mailing address, street address, fax and telephone number: Publication in consolidated and revised form authorised by the Governor in Council this 25th day of January, 2000. Carmena H. Parsons Clerk of Executive Council 19