Civil Servants and Pensioners
Enrollment Requirements
In order for a Plan Member to be enrolled in the Plan they must comply with the enrollment procedures outlined by the PoCS for Employees, or PSPB with regard to Retirees. Current procedures are included in Appendix A of the Plan.
Effective Dates
A Plan Member will be covered under this Plan as of the first day that they satisfy the:
- The Eligibility Requirements of the Plan (see page 12 of the Plan);
- The Enrollment Requirements of the Plan (please see Appendix 5 of the Plan).
A Dependent’s and Dependent Offspring’s coverage will take effect on the day that it is demonstrated (a) that the eligibility requirements are met; and (b) the Plan Member is covered under the Plan; and (c) the enrollment requirements are met.
Retroactive Enrollment
Retroactive enrollment is permitted up to a maximum of 90 calendar days.
Enrollment Requirements For New Born Child
A newborn child of a Plan Member is automatically enrolled in this Plan for 90 days from birth. Charges for covered benefits (including nursery care), will be applied toward the Plan of the newborn child. If proper documentation is not received within the first 90 days from birth, coverage for the newborn will terminate on the 91st day. Coverage will be reinstated upon receipt of the relevant documentation.
Change in Family Circumstances
The Plan permits a change of benefit coverage during the plan year if a qualified change in family circumstance occurs. The procedures for making changes to family circumstances will be determined by the Employer or in the case of Retirees the Public Service Pensions Board (PSPB). Plan Members are, by law, responsible for notifying the Employer or PSPB when family circumstances affecting eligibility for medical coverage change.
Employer Liabilities
Where the potential Plan Member has met the eligibility and enrollment requirements of the Plan but the Employer/PSPB has failed to comply with the enrollment requirements of the Plan on their behalf, the liability for medical expenses incurred in that period by the Employee/Retiree and their Dependent will be met by the Plan Members Employer (the Ministry/Portfolio/Department)/PSPB.
Termination of Coverage
The Plan Participants coverage under the Plan will terminate on the earliest of these dates:
- The date the Plan is terminated.
- The first day of the month following the date they cease to be eligible under the plan.
The Plan Administrator is required to provide Plan Members with the opportunity of purchasing up to 3 months additional coverage under the Plan, once eligibility for this plan automatically ends.
A former Employee who is re-hired after a break of more than 6 months, will be treated as a new hire and be required to satisfy all eligibility and enrollment requirements.
This health plan provides health care coverage for the entire Civil Service and their dependents, as well as retirees. In addition, a number of Statutory Authorities & Government Companies also subscribe to this plan.
Enrollment Criteria
(Exclusively for Cayman Islands Government Civil Servants and Pensioners & Employees of participating Statutory Authorities and Government Companies)
New Employees and their Dependents
- Eligibility for Plan benefits for Employees and Dependents will be negotiated as part of the recruitment and selection process and documented in the Employee Agreement.
- The required supporting documentation must be provided by the Employee as part of their pre/new employment administration.
- The Ministry/Portfolio/Department must ensure entry of relevant information into the HRIRIS system on commencement of employment.
- Information regarding Plan eligibility will be automatically transferred electronically to CINICO’s NHIS database, and CINICO will produce and distribute CINICO cards for the Employee and Dependent(s).
Existing Employees and their Dependents
- Employees must notify their Department immediately of changes to their circumstance or that of their Dependents impacting eligibility for Plan benefits. This is required under Schedule 1 Section 13(1)(b) of the Personnel Regulations. The table below identifies the supporting documentation needed to support each request. A Change Of Circumstance Form must be completed and submitted in each case.
- The Ministry/Portfolio/Department must consider whether the request requires a variation to the employee’s terms and conditions and must issue an amendment to the Employee Agreement where a contractual change is being authorized.
- The Ministry/Portfolio/Department must ensure the update of relevant information into the HRIRIS system with immediate effect.
- Updated HRIRIS information regarding Plan eligibility will be automatically transferred electronically to CINICO’s NHIS database and CINICO will produce/distribute/deactivate CINICO cards as appropriate.
| Change of Circumstance | Supporting Documents |
|---|---|
| Marriage | Marriage Certificate and Spouse’ Birth Certificate |
| Becoming step-parent | Marriage Certificate and child’s Birth Certificate |
| Birth of Child | Child’s Birth Certificate DNA test results where a male employee is not listed as the parent of the child on the Child’s Birth Certificate. |
| Adoption of Child | Adoption Certificate Child’s Birth Certificate(If adoption is accompanied by a name change see name change section below) |
| Child aged 18 to 23 in full-time education | Proof of enrolment in full-time course at school/university |
| Child under 18 commencing employment | Letter from employer identifying child is covered for medical benefits under the employer |
| Marriage of child aged 18 to 23 in full-time education | Marriage Certificate |
| Death of Spouse of Child | Death Certificate |
| Divorce | Dissolution of Marriage Certificate (If divorce is accompanied by a name change see name change section below) |
| Name Change | Copy of Deed Poll |
| Change of Postal Address | Nothing in addition to the Change of Circumstance Form |
Dependent Offspring of Existing Employees (optional at the expense of the member and with prior approval).
- Employees must request eligibility for Plan benefits for Dependent Offspring from the Ministry/Portfolio/Department.
- The Ministry/Portfolio/Department (in conjunction with PoCS) must consider whether or not a Dependent Offspring can be added to the Employee’s Plan in accordance with the policy of the PoCS.
- The Ministry/Portfolio/Department must ensure entry of relevant information into the HRIRIS system (including salary deductions where appropriate).
- Updated HRIRIS information regarding Plan eligibility will be automatically transferred electronically to CINICO’s NHIS database and CINICO will produce and distribute CINICO cards as appropriate.
Terminated Employees and their Dependents/Dependent Offspring
The Employer will be responsible for maintaining and timely furnishing to CINICO, current and accurate Plan eligibility.
- Changes affecting the status of any of the Plan Participants must be submitted to CINICO within 10 business days after the Employer becomes aware of any such change.
- CINICO will not be responsible for errors or omissions arising out of the failure to maintain current and accurate eligibility data held on HRIRIS.
- In the event of retrospective changes in status of more than 30 days, CINICO reserves the right to seek recovery of paid claim(s) from the Ministry/Portfolio/Department.
New Retirees and their Dependents
- On the retirement of a Plan Participant from the Civil Service (who was entitled to a Pension, or was already a member of the Public Service Pension Scheme that he/she can now claim under, and the Government was their principal employer for at least 10 consecutive years), PSPB will enter the pensioner’s details (and their Dependents) onto the NHIS database.
- In cases where the eligibility conditions detailed above appear not to have been met, the pensioner may be referred to PoCS to determine whether PSPB should still add them to the NHIS database. PSPB will only act in these cases on the written instruction of PoCS.
- Once CINICO cards have been received, PSPB will contact the pensioner for pick up.
Amending Retiree (pensioner) and Dependent Details
- Upon notification of changes to a Retiree’s circumstances and on receipt of required documentation, PSPB will make the necessary amendments to the NHIS database.
- If the amendment requires new CINICO card(s) to be issued, then PSPB will contact the Retiree/pensioner on receipt of the card(s) to arrange pick up.
- If the maximum age is reached for Retiree’s Dependents, or notification is received that their Dependents have ceased to be in full time education, then their Dependents will be end dated by PSPB on the NHIS database.
| MEDICAL CARE BENEFITS | In- Network (Health Services Authorities) | On-Island or Overseas Providers without Referral * | On-Island or Overseas Providers with Referral within CINICO Preferred Provider Network | On-Island or Overseas Providers with Referral outside CINICO Preferred Provider Network |
|---|---|---|---|---|
| ** Maximum Lifetime Benefit Amount: CI $5 Million | ||||
| Covered Services: All Covered Expenses are payable subject to a fee schedule or negotiated rate | ||||
| Hospital Services | ||||
| Room and Board | 100% of the semi-private room rate | No Coverage | 100% of the semi-private room rate | 90% of the semi-private room rate |
| Skilled Nursing Facility | 100% of the facility’s semi-private room rate | No Coverage | 100% of the facility’s semi-private room rate | 90% of the facility’s semi-private room rate |
| Physician Services | ||||
| Inpatient visits | 100% | No Coverage | 100% | 90% |
| Office visits | 100% | No Coverage | 100% | 90% |
| Surgery | 100% | No Coverage | 100% | 90% |
| Allergy testing | 100% | No Coverage | 100% | 90% |
| Allergy serum & injections | 100% | No Coverage | 100% | 90% |
| Home Health Care | $6000 maximum per month, in accordance with approved Home Health Care Plan | |||
| Prescription Drugs | 100% | No Coverage | 100% | 90% |
| Ambulance Service (Ground & Air) | 100% | No Coverage | 100% | 90% |
| Occupational Therapy | 100% | No Coverage | 100% | 90% |
| Speech Therapy | 100% | No Coverage | 100% | 90% |
| Physical Therapy | 100% | No Coverage | 100% | 90% |
| Durable Medical Equipment | 100% | No Coverage | 100% | 90% |
| Prosthetics | 100% | No Coverage | 100% | 90% |
| Orthotics | 100% | No Coverage | 100% | 90% |
| Spinal Manipulation/Chiropractic | 100% Maximum 20 visits per annum | No Coverage | 100% Maximum 20 visits per annum | 90% Maximum 20 visits per annum |
| Mental Disorders | ||||
| Inpatient | 100% | No Coverage | 100% | 90% |
| Partial Hospitalization | 100% | No Coverage | 100% | 90% |
| Outpatient | 100% | No Coverage | 100% | 90% |
| Substance Abuse-Inpatient Detoxification Services Only | 100% | No Coverage | 100% | 90% |
| Preventive Care – Includes office visits, pap smear, mammogram, prostate screening, gynecological exam, routine physical examination, x-rays, laboratory blood tests and immunizations. | ||||
| Routine Well Adult Care | 100% | No Coverage | 100% | 90% |
| Routine Well Newborn Care | 100% | No Coverage | 100% | 90% |
| Routine Well Child Care | 100% | No Coverage | 100% | 90% |
| Immunizations – Children to Adult | No Coverage | 100% as ordered by a physician | 90% as ordered by a physician | |
| Organ Transplants | 100% | No Coverage | 100% | 90% |
| Pregnancy | 100% | No Coverage | 100% | 90% |
*Overseas Medical Emergency Care only covered at a 100%
** Any benefit which exceeds the maximum lifetime benefit amount is an assumed risk of the Government Entity through whole the Plan Participant is eligible.
| VISION CARE BENEFITS |
|---|
| One eye examination per Plan Participant in 24 month period, up to a maximum of $60 (or for Pilots – one eye examination in a six month period, or for Scenes of Crime Officers – one eye examination in a twelve month period). |
| One pair of prescription glasses in a 24 month period, up to a maximum of $300 (including frames), or equivalent in contact lenses. |
| DENTAL CARE BENEFITS |
|---|
| Class A (Preventative and Diagnostic) – 100% |
| Includes – routine oral examinations, one bitewing once per calendar year, two full mouth x-rays every 24 months, four fluoride treatments per calendar year for Dependent children under 19 years old, two visits per calendar year for scaling and polishing of teeth, and emergency palliative treatment for pain. |
| Class B (Basic Procedures) – 100% |
| 100%. Includes oral surgery, periodontics, endodontics, extractions, re-cementing and fillings (other than gold, or material more expensive than gold). |
| Class C (Major Procedures) – 100% |
| Includes the installations and creation of crowns. |
| Class C (Major Procedures) – 50% |
| Dentures & Orthodontia. Installing, replacing or repairing removable dentures. |
| Not Covered |
| Gold restorations, including inlays, onlays and foil fillings, implants and bridgework. |
- Health Policy
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