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.
A Plan Member will be covered under this Plan as of the first day that they satisfy the:
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 is permitted up to a maximum of 90 calendar days.
ENROLLMENT REQUIRMENTS FOR NEWBORN CHILDREN
A newborn child of a Plan Member is<00zh> 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 <00xh>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 CIRCUMSTANCE
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.
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 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.
(Exclusivly for Cayman Islands Government Civil Servants and Pensioners & Employees of participating Statutory Authorities and Government Companies)
New Employees and their Dependents
Existing Employees and their Dependents
|Change of Circumstance||Supporting Documentation|
|Marriage||Marriage Certificate and Spouse'
Marriage Certificate and child’s
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
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
Marriage of child aged 18 to 23 in full-time education
Child under 18 commencing employment
Letter from employer identifying child is
covered fo medical benefits under
Death of Spouse of Child
Dissolution of Marriage Certificate (If
divorce is accompanied by a name
change see name change section below)
Copy of Deed Poll
Change of Postal Address
Nothing in addition to the Change of
Dependent Offspring of Existing Employees (optional at the expense of the member and with prior
Terminated Employees and their Dependents/Dependent Offspring
The Employer will be responsible for maintaining and timely furnishing to CINICO, current and accurate
New Retirees and their Dependents
Amending Retiree (pensioner) and Dependent Details
|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|
|Room 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|
|Inpatient visits||100%||No Coverage||100%||90%|
|Office visitis||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%|
|Spinal Manipulation/Chiropractic||100% Maximum 20 visits per annum||No Coverage||100% Maximum 20 visits per annum||90% Maximum 20 visits per annum|
|Partial Hospitalization||100%||No Coverage||100%||90%|
|Substance Abuse-Inpatient Detoxification Services Only||100%||No Coverage||100%||90%|
|Preventive Care - Includes office visits, paps smear, mammogram, prostate screening, gynecological exam, routine physcal 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%|
* 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 whol the Plan Participant is eligible.
|VISON CARE BENEFITS|
|One eye examination per Pan Participant in 24 month period, up to a maximum of $60 (or for Pilots – one eye examination in a siz 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.|
|Gold restorations, including inlays, onlays and foil fillings, implants and bridgework.|